Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF criteria. The Plan denied 
your request. The Plan says that the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are concerned that you are not mobile after the 
accident. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the thorax and 
abdomen and pelvis. 
 
You asked the Plan to pre-approve the CT scans. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the CT scans do not meet requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scans. Our reviewer says that 
the requested CT scans are not considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found the records does not indicate previous x-rays, ultrasounds, or gastrointestinal 
(GI) consult have been provided. Medical necessity of the CT scans has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) scans of the thorax and abdomen and pelvis.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for additional home health services provided from November 29, 2022, to 
December 14, 2022.  
 
You asked the Plan to pay for home health services. You say that the home health services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the services were not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for home health services. Our reviewer says that 
the services are medically reasonable and necessary. Our physician reviewer found that there is documentation 
that skilled nursing services were required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's 
condition and/or prevent deterioration from November 29, 2022, to December 14, 2022. The provided medical 
records document on November 29, 2022, December 6, 2022, and December 14, 2022, that the enrollee had a 
recent emergency room visit for chest pain. Records on December 14, 2022, report a new prescription for 
omeprazole due to the chest pain. Records also document worsening lower extremity edema with a 7.3 pound 
weight gain and poor patient understanding of dietary sodium restriction. Records also report a new symptom 
of itching for which a physician evaluation was recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pay for additional home health services provided from November 29, 2022, to December 14, 2022.    
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology procedure, level 4 (81403). 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee needs the requested test. The Plan 
denied your request. The Plan says the requested test is not an approved test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that according to the MolDX Technical 
Assessment, the requested test is not an approved test. Based on this information, we decided that Medicare 
rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve molecular pathology procedure, level 4 (81403).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on July 30, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
Plan has not received the Explanation of Benefits (EOB) from the primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the EOB from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
emergency department visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit provided on July 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes J96.01 
and E87.2 rendered from September 6, 2021, to September 9, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
appealing the partial DRG adjustment recoupment. The Plan denied your request. The Plan says a post-service, 
post-payment Clinical Validation Audit was performed to ensure that the diagnosis codes on the claim 
supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes J96.01 and E87.2. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that in this case, there was no clinical or laboratory evidence of acute respiratory 
failure with hypoxia or acidosis. The documentation did not support diagnosis codes J96.01 (acute respiratory 
failure with hypoxia) and E87.2 (acidosis). The records more support DRG 195.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis codes J96.01 and E87.2 rendered from September 6, 2021, 
to September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and testing provided from October 14, 2022, 
to October 25, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that this is the only health insurance plan that 
you had at the time you received the services. You say that you paid a copayment of $30. You also say that you 
are now being billed for the total. The Plan denied your request. The Plan says an Evidence of Benefits from 
the primary insurance on the date of service in this case has not been received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the outpatient services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the office visit and testing provided from October 14, 2022, to 
October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound polymerase chain reaction (PCR) panel provided on 
December 22, 2022, and billed with codes 87798, 87653, 87651, 87641, 87551, 87500, 87481 and 87471. 
 
You asked the Plan to pay for a wound PCR panel. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing should be billed under a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of a wound PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for a wound polymerase chain reaction (PCR) panel 
provided on December 22, 2022, and billed with codes 87798, 87653, 87651, 87641, 87551, 87500, 87481 and 
87471.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for primary percutaneous transluminal mechanical thrombectomy rendered 
on January 26, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 37184 is "Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, 
arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological 
thrombolytic injection(s); initial vessel." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that there is documentation of Angiojet 
mechanical thrombectomy being performed to the femoral-popliteal artery bypass with satisfactory description 
of findings. With additional stenting, a successful result was achieved.  As there is satisfactory documentation 
that the work coded for in code 37184 was rendered, the code is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
primary percutaneous transluminal mechanical thrombectomy rendered on January 26, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravascular ultrasound services (procedure codes 37252 
and 37253) rendered on February 13, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 37252: 
 
Intravascular ultrasound (IVUS) (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support the use of the codes in question. CPT 37252 and 37253 code for supervision and interpretation of 
IVUS. In this case, there is unsatisfactory documentation of IVUS interpretation/findings on which to justify 
the billing and coverage of these services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for intravascular ultrasound services (procedure codes 37252 and 37253) rendered on February 13, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 10, 2023, to  
January 30, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the counselor was highly recommended by a 
neighbor and since you live in a small community with very few options, you took advantage of her help. You 
say that this provider was very effective at reviewing your mental-health plan so that you can manage on your 
own and in the future and you do not plan to see her again. The Plan denied your request. The Plan says a 
Licensed Mental Health Counselor (LMHC) is an excluded provider type. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 10, 2023, to 
January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247, 37220, 37222, and 75625 rendered 
on July 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 36247: 
 
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family 
 
CPT 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 
CPT 37222: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal angioplasty (List separately in addition to code for primary procedure) 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support coverage of the codes in question. The documentation is inadequate on which to justify billing and 
coverage. There is no documentation of access or catheterization (36247), insufficient detail with respect to 
intervention (37220 and 37222), and substantial portions of the operative note do not apply to the procedure 
performed including documentation of vicryl, nylon sutures, and staples (if needed). There is insufficient 
documentation of findings with respect the aorta to justify billing and coverage of aortogram supervision and 
interpretation (75625). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36247, 37220, 37222, and 75625 rendered on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service July 2, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service July 2, 2022.