Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 23, 2023, billed with codes 
87798, 87481, 87556, 87640, 87653, 87651, and 87500. 
 
You asked the Plan to pay for the testing billed. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was a  panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the testing billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on March 23, 2023, 
billed with codes 87798, 87481, 87556, 87640, 87653, 87651, and 87500.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity/ankle-foot orthosis (L1970, L2999). 
 You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show that the enrollee is not ambulatory. 
 
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 the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee is ambulatory. The enrollee has 
weakness/deformity of the feet/ankles on exam. The enrollee does not require foot or ankle stabilization for 
medical reasons. The enrollee does not require the orthosis to benefit functionally. The enrollee has bilateral 
ankle contractures. The enrollee does not require  knee extension assist in the absence of any co-existing joint 
contracture, or require assist with ankle plantar or dorsiflexion assist in the absence of any co-existing joint 
contracture. The criteria has not been met. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lower extremity/ankle-foot orthosis (L1970, L2999).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the neurological or neuromuscular diagnostic procedure (95999), 
needle electromyography (codes 95865 and 95868), somatosensory testing (95938), and central motor evoked 
potential study (95939) provided on June 21, 2022. 
 
You asked the Plan to pay for the neurological or neuromuscular diagnostic procedure, needle 
electromyography, somatosensory testing, and central motor evoked potential study. The Plan denied your 
request. The Plan says that charges for or in connection with services or supplies that are, as determined by the 
Plan, considered to be experimental or investigational are excluded from coverage under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the neurological or neuromuscular 
diagnostic procedure, needle electromyography, somatosensory testing, and central motor evoked potential 
study. Our physician reviewer found that neurological or neuromuscular diagnostic procedure (95999), needle 
electromyography (codes 95865 and 95868), somatosensory testing (95938), and central motor evoked 
potential study (95939) are standard procedures generally recognized as reasonable and necessary for cervical 
spine surgery. 
 
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 neurological or neuromuscular diagnostic procedure, needle 
electromyography, somatosensory testing, and central motor evoked potential study have been met. Therefore, 
we decided that the Plan has to pay for the neurological or neuromuscular diagnostic procedure (95999), needle 
electromyography (codes 95865 and 95868), somatosensory testing (95938), and central motor evoked 
potential study (95939) provided on June 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for G0108. We decided that the Plan does not have to pay for 96366.  
 
You asked the Plan to pay for procedure codes 96366 and G0108 rendered on January 4, 2023.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for G0108.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of Healthcare Common 
Procedure Coding System (HCPCS) G0108 is "Diabetes outpatient self-management training services, 
individual, per 30 minutes." 
 
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 for G0108. Our reviewer says that the procedure report 
describes diabetes training services for 20 minutes. Therefore, this code is supported. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
G0108.  
 
We also decided that the Plan does not have to pay for 96366. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 96366 is "Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure)." 
 
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 for CPT 96366. Our reviewer says that the procedure 
report describes intravenous insulin treatment provided for an outpatient. In this case, there is a more 
appropriate code for the documented services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 96366 have not been met. Therefore, we decided that the Plan does not have to 
pay for 96366. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has medical needs that 
exceed skilled nursing facility capabilities and will likely need 25 days or longer in LTACH level of care due to 
their complexity. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The enrollee is receiving appropriate care at the 
present acute care hospital. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power wheelchair (PWC) (K0813). 
 
You asked the Plan to pre-approve a group 1 standard PWC. The Plan denied your request. The Plan says the 
enrollee has upper extremity muscle strength to self-propel a manual wheelchair, not meeting the Medicare 
coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 1 standard PWC. Our reviewer 
says that the coverage criteria have not been met. Our physician reviewer found the records consistent of a 
standard prescription for the device. Our reviewer also found that there is no physical exam or evidence the 
device may be safely used or is medically 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 a group 1 standard PWC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power wheelchair (PWC) (K0813).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801 rendered on February 6, 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 87150: 
 
Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or 
isolate, each organism probed 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87641: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
CPT 87801: 
 
Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique 
 
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 units of service for CPT 
87801 cannot be verified. CPT codes that test for multiple infectious agents are reported with one unit of 
service if one procedure, one methodology, or one test kit is used to perform the test (e.g., 87300, 87451, 
87800, 87801). When multiple procedures, multiple methodologies, or multiple kits are medically necessary 
and used to perform a test for multiple infectious agents, the units of service reported for CPT codes that 
identify multiple infectious agents equals the number of different procedures, methodologies, or kits used to 
perform the test. 
 
In terms of the remainder of the codes, modifier XU was reported on all of the codes to report an unusual non-
overlapping service. The laboratory report does not contain any documentation to confirm this modifier. 
 
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 87150, 87481, 87641, 87653, 87798, and 87801 rendered on February 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 1, 2022, to 
March 2, 2022. 
 You asked the Plan to pay for the home health services. You say that a corrected NOA was submitted. The Plan 
denied your request. The Plan says the NOA was not received timely. 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 February 1, 2022. The NOA was not received by the Plan until March 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, 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 February 1, 2022, to March 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 1, 2022, to 
October 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 October 1, 2022, to 
October 30, 2022.  
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding 
the submission of a corrected claim need to be sent to the Plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is necessary because you are 
bedridden and no longer have home health services for your wound care. The Plan denied your request. The 
Plan says based on the medical records received, your condition does not meet Medicare guidelines 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 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 you may have a need for physical therapy 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 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible applied for the chiropractic manipulative 
treatments (98941 x 4) provided from March 29, 2023, through April 12, 2023. Additionally, the Plan does not 
have to pay for the hot or cold packs therapy (97010), electrical stimulation (G0283), and the office visit 
(99202) provided from March 29, 2023, through April 12, 2023. 
  
 
 
 
You asked the Plan to waive the deductible for the chiropractic manipulative treatments. Additionally, you 
asked the Plan to pay for the hot or cold packs therapy, electrical stimulation, and the office visit. You say that 
you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan 
says the deductible was charged correctly for the chiropractic manipulative treatments provided. Additionally, 
the Plans says the only covered chiropractic service is manual manipulation of the spine to correct a 
subluxation.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that enrollees must pay a 
$1,000 yearly deductible.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
 
You have been asked to pay $159.80 (Plans allowed amount of $39.20 x 4) for the chiropractic manipulative 
treatments provided as you have not previously met the Plans yearly deductible. Your contract with the Plan 
clearly says that enrollees must pay a $1,000 yearly deductible. Until you have paid the deductible amount, you 
must pay the full cost for most of your covered services. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Additionally, the Plans contract states that the only covered chiropractic 
service is manual manipulation of the spine to correct a subluxation. Therefore, we decided that the Plan does 
not have to waive the deductible applied for the chiropractic manipulative treatments (98941 x 4) provided 
from March 29, 2023, through April 12, 2023. Additionally, the Plan does not have to pay for the hot or cold 
packs therapy (97010), electrical stimulation (G0283), and the office visit (99202) provided from March 29, 
2023, through April 12, 2023.