Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 00840-AA-P4. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100-GY.  
 
You asked the Plan to pay for practitioner services provided on April 4, 2023, billed with procedure codes 
00840-AA-P4 and 99100-GY. You say that the claim is billed correctly and should be paid. The Plan says that 
code 99100 is considered bundled and is not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 00840-AA-P4.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 00840-AA-P4.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100-GY. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99100-GY have not been met. We have confirmed that 
code 99100 has a status indicator B and is not separately payable. Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code(s) 99100-GY. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
April 29, 2023, billed with code 99232-FS. 
 
You asked the Plan to pay for the EM services as billed. You say that this code should be paid. The Plan denied 
your request. The Plan says this is not allowed for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that EM services from a physician of the same 
specialty can be paid on the same date as critical care services when the criteria in the Medicare rules section 
are met, and modifier 25 is used.   
We looked at the file and Medicare rules. The physician at issue is the same specialty as a physician providing 
critical care services on the same date. The EM services were not billed with modifier 25 to allow separate 
payment. Based on this information, we decided that Medicare rules for coverage of the EM services as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management (EM) services provided on April 29, 2023, billed with code 99232-FS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214), intravenous infusion (96365, 96366) 
and refilling and maintenance of a portable pump (96521) provided on July 26, 2023. 
 
You asked the Plan to pay for an office visit and intravenous infusion. You say that you disagree with the 
denial and have submitted medical records for review. The Plan denied your request. The Plan says the codes 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 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 an office visit and intravenous infusion. Our reviewer says 
that the services do not meet criteria for payment on this claim. Our reviewer found that for code 99214, 
although an appropriate history and/or exam is documented in the medical record, moderate level of medical 
decision making is not supported, and therefore cannot be verified.  In this case, low level of medical decision 
making is supported. For codes 96365 and 96366, the medical record describes intravenous insulin treatment 
provided for an outpatient on July 26, 2023. In this case, there are more appropriate codes that should be 
reported for service provided. For code 96521, the medical record does not include documentation of refilling 
and maintenance of portable pump. Was unable to cite report, as this procedure was not found in medical 
record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit and intravenous infusion have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (99214), intravenous infusion (96365, 96366) and 
refilling and maintenance of a portable pump (96521) provided on July 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 15, 2023 to 
March 20, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the billed DRG is not supported. 
 
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 code A41.3. 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 the documentation does not support the diagnosis of sepsis, as it not readily apparent that 
the patient had the necessary signs of end organ damage that are needed to make that diagnosis.  
 
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 provided on March 15, 2023 to March 20, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 30, 
2023, to April 13, 2023. 
 
You asked the Plan to pay for SNF care. You say that services which the enrollee required and received during 
this period are coverable. The Plan denied your request. The Plan says criteria for a SNF stay have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the limited documentation provided, the enrollee did not qualify for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs were custodial and could, as a practical 
matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 30, 2023, to April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic screening for primary immunodeficiency disorder 
provided on May 9, 2023.   
You asked the Plan to pay for the genetic screening panel. You say that this was medically necessary as the 
enrollee has an immune deficiency. The Plan denied your request. The Plan says this was screening testing.  
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
This testing was provided in the absence of signs and symptoms of immune deficiency. While rheumatoid 
arthritis is immune-related, it is an autoimmune disease, not an immune deficiency. As such, this testing was 
provided for screening purposes.  Therefore, we decided that the Plan does not have to pay for the genetic 
screening for primary immunodeficiency disorder provided on May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the records provided support the 
need for the item in dispute. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary for this enrollee because their needs can be met with an alternative device such as a BiPAP device 
with average volume-assured pressure support (AVAPS).   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has very severe obesity, obstructive sleep apnea, pulmonary hypertension, 
and is on chronic narcotics. A diagnosis of COPD is listed, although the record indicates that past spirometry 
showed restrictive lung disease, and the enrollee's primary respiratory issue is obesity hypoventilation 
syndrome. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. An arterial blood gas 
from January 9, 2020, showed a normal pH and a very minimally elevated PaCO2. The enrollee was recently 
hospitalized for an exacerbation of heart failure. No more recent arterial blood gas is provided. If this patient 
has chronic carbon dioxide (CO2) retention, may benefit from BiPAP with average volume assured pressure 
support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy to be provided by an out-of-network provider. The Plan 
denied your request. The Plan says the member must receive care from a network provider.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 rendered on June 27, 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 service is not supported by the records. 
 
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 83789 is "Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen." 
 
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. Our reviewer found that the laboratory report describes specimen validity testing 
for a urine drug test. Specimen validity testing is included in the presumptive and definitive drug testing code 
description. It is considered quality control which is an integral part of the collection process. It is not 
separately reimbursable. 
 
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 code 83789 rendered on June 27, 2023.
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 requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status.  The enrollee can receive further services at a lower 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 11, 
2023, to June 10, 2023. 
 You asked the Plan to pay for SNF care. You say that the records provided support that the services in dispute 
were medically necessary and appropriate. The Plan denied your request. The Plan says the enrollee's condition 
no longer required SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee no longer qualified for SNF coverage. The enrollee did not have 
documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled 
services were not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, could, as a practical matter, have been 
provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 11, 2023, to June 10, 2023.
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 appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet the guidelines for IRF services.  
 
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 the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that they would meet criteria for admission to an IRF.  There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status.  The 
enrollee can receive further services at a lower 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 27, 
2023, to June 26, 2023. 
 
You asked the Plan to pay for SNF care. You say that services which the enrollee required and received are 
coverable. The Plan denied your request. The Plan says no skilled services were provided (rehabilitative or 
nursing) during the dates in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee no longer qualified for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs were custodial and could, as a practical 
matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 27, 2023, to June 26, 2023.