Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 15, 2023, 
to March 16, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted 
electronically on February 16, 2023. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 15, 2023, to 
March 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 23, 2022, to 
October 22, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the NOA. The Plan 
denied your request. The Plan says the NOA was not received. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 23, 2022. The NOA was not received by the Plan.  Although 
you contend that a NOA was provided, the only information you submitted in support of your assertion is a 
document called a "Start of Care Comprehensive Assessment."  This is not a NOA. As a result, no payment can 
be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services 
provided from September 23, 2022, to October 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services to address 
functional deficits and regain their independence. The Plan denied your request. The Plan says the request is 
not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty (15822). 
 
You asked the Plan to pre-approve blepharoplasty. You say that this issue is affecting your vision, and 
correction is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of this 
service are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve blepharoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that you have Blepharochalasis. The record provided does not provide 
primary source documentation of a visual field deficit of a severity that is enumerated in the coverage 
rules. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is 
not 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 blepharoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve blepharoplasty (15822).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical procedures, the laboratory services, and the office visits 
provided from April 21, 2022, to October 19, 2022. 
 
You asked the Plan to pay for the surgical procedures, the lab services, and the office visits. You say that you 
are requesting reconsideration of the denied claims. The Plan denied your request. The Plan says that this 
service was not authorized. 
 
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. The Plan has not provided the correct Evidence of Coverage showing the 
contractual agreement for the use of in-network providers. Therefore, we decided that the Plan has to pay for 
the surgical procedures, the laboratory services, and the office visits provided from April 21, 2022, to October 
19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot billed for date of service February 21, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim was 
not billed with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that CPT code L4361-RT was not billed with a KX, GA, or GZ modifier as required. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the walking boot billed for date of service February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment billed for date of service December 21, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was given to the enrollee in an 
office setting. The Plan denied your request. The Plan says that the claim was billed with an inappropriate place 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. The enrollee was not in an institution. CPT code L1833 was dispensed in 
the office for use in the enrollees home. Based on this information, we decided that Medicare rules for 
coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for the durable 
medical equipment billed for date of service December 21, 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 pay for procedure codes 87150, 87481, 87653 and 87641 billed for 
date of service December 5, 2022. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87653 and 87641. You say that these services 
were reported correctly. The Plan denied your request. The Plan says these services are not supported for 
separate payment. 
 
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, we have confirmed that codes 87150, 87481, 87653 and 87641 are each column II codes to column 
I codes 87500, 87150 and/or 87801. Code 87481 was not billed with an appropriate modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met for code 87481. However, codes 
87150, 87653 and 87641 were each billed with a modifier.  
 
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 procedure codes 87150, 87653 and 87641. Our reviewer says 
that these services are not supported for separate payment. Our reviewer found the laboratory report does 
include documentation to support that these were unusual non-overlapping services from the column 1 code(s). 
Therefore, these procedures denied correctly, and billing separately cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87653 and 87641 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653 and 87641 billed for 
date of service December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Artacent AC, per sq cm (Q4190) and application of skin 
substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, 
total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (15275). 
 
You asked the Plan to pre-approve Artacent AC and application of skin substitute graft. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve Artacent AC and application of skin 
substitute graft. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found records do not show that the enrollee's vascular situation has been reassessed following her complaints of a cold foot. They do not show that she has adequate 
blood flow to heal her wound. They do not show that infection is controlled, that blood sugars are controlled, or 
that the enrollee is offloading the wounds. The review has determined that the items/services at issue in this 
case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Artacent AC and application of skin substitute graft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Artacent AC, per sq cm (Q4190) and 
application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or 
multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (15275).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on December 19, 2022, billed 
with codes 70100, 70310, 72040, 74230 and 74240. 
 
You asked the Plan to pay for radiology services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the documentation supports the studies 
represented were performed at a nursing home which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which 
another POS code already exists, providers should use the POS code for that entity. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiology services have not been met. Specifically, the record shows that this claim was billed with 
POS code 11 indicating that the services were rendered in an office setting. The documentation submitted 
indicates that the mobile unit for the services at issue was serving a Skilled Nursing Facility. POS 11 is not 
appropriate in this case. Therefore, we decided that the Plan does not have to pay for radiological services 
provided on December 19, 2022, billed with codes 70100, 70310, 72040, 74230 and 74240.
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 still unable to get around on your own and 
you need to continue rehab. 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. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. 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. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0442 and G0446 billed for date of service 
October 5, 2022. 
 You asked the Plan to pay for procedure codes G0442 and G0446. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says payment for procedure codes G0442 and G0446 is 
included in the payment for codes 99214 and 99497. 
 
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, we have confirmed that codes G0442 and G0446 are column II codes to column I codes 9914 and 
99497; however, G0442 and G0446 were billed with a modifier.  
 
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 procedure codes G0442 and G0446. Our reviewer says that 
procedure codes G0442 and G0446 do not meet criteria for payment. Our reviewer found that procedure code 
G0442 and modifier cannot be verified in the provided documentation as a distinct procedural service. 
Procedure code G0446 cannot be verified in the medical record as performed. The provided documentation 
describes the guideline for reporting procedure; however, intensive behavioral therapy for cardiovascular 
disease cannot be verified, as the actual discussion was not documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes G0442 and G0446 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes G0442 and G0446 billed for date of service October 5, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 25, 2022, to 
December 24, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the NOA on October 28, 
2022.  You stated that this NOA was received. The Plan denied your request. The Plan says although you stated 
that you supplied the required NOA, a valid NOA is not on file. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the Plan has confirmed that it has not received a NOA from you for this claim, so no payment can 
be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services 
provided from November 25, 2022, to December 24, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on January 27, 2021, to January 
31, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says that 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 I21.A1. 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 use of diagnosis code I21.A1 is supported by the records provided. Our physician 
reviewer found that the enrollee had very elevated troponin without signs of unstable angina, which is 
consistent with type II Non-ST-Elevation Myocardial Infarction (NSTEMI), and thus meets criteria for 
diagnosis code I21.A1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on January 27, 2021, to January 31, 2021, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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: Favorable

 
We decided that the Plan has to pay for procedure code 99306 for date of service October 9, 2022. 
 
You asked the Plan to pay for procedure code 99306. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services billed 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. In this case, the CPT Code Manual definition of 
code 99306 is initial nursing facility care, per day, for the evaluation and management of a patient, which 
requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical 
decision making of high complexity. Counseling and/or coordination of care with other physicians, other 
qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 
45 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
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 procedure code 99306. Our reviewer says that the 
documentation supports the code billed Our reviewer found the enrollee has a history of diabetes and peripheral 
artery disease. The enrollee presented with a non-healing gangrenous foot ulcer and diagnosed with 
osteomyelitis. The documentation supports a comprehensive history, exam, and medical decision making of 
high complexity. Therefore, code 99306 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 procedure code 99306 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99306 for date of service October 9, 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.