Persius/hicric huggingface dataset:
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 meets LTACH criteria, and 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
admission to an LTACH 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 appears to be improving slowly but still somewhat unstable and 
requires additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous at this time.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 15, 
2023, through April 23, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
  
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with intermittent abdominal pain, 
nausea, vomiting, and diarrhea for one week and possible malnutrition. She was in the ED the day prior for the 
same symptoms. Her blood pressure was high initially and lowered after initial treatment. Her creatinine was 
2.2. The urine drug screening was positive for opiates. She was started on intravenous fluids and soon tolerated 
oral clear fluids. Her abdomen was nontender, soft, and non-distended. The physical exam was otherwise 
unremarkable. She was not in any distress and was alert and oriented. No acute findings were identified on 
imaging. She was treated with pain medication. Based on the presentation and clinical workup being low 
complexity and low severity, it was not expected that the enrollee would have required hospital care that would 
have likely crossed two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from April 15, 2023, through April 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Interspinous decompression spacer procedure. 
 
You asked the Plan to pre-approve an Interspinous decompression spacer procedure. You say that the need for 
the requested procedure to treat lumbar spinal stenosis with neurogenic claudication is supported by the 
medical records provided. The Plan denied your request. The Plan says the requested device has not been 
shown to be safe and effective for treatment of the enrollee's condition. 
 
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 an Interspinous decompression spacer 
procedure. Our reviewer says that an Interspinous decompression spacer procedure is not considered medically 
reasonable and necessary in this case. Our physician reviewer found Interspinous process spacers are 
experimental. More research is needed to show safety and efficacy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Interspinous decompression spacer procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Interspinous decompression spacer procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 11, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on February 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203-25 rendered on December 19, 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 Current Procedural Terminology (CPT) code 99203-25 (1 Unit ) remains not supported, as the 
use of the -25 modifier is not appropriate. 
 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 99203 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 30-44 minutes of 
total time is spent on the date of the encounter." 
 
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 medical and billing records 
demonstrate that CPT 25600 was performed on December 19, 2022. This procedure has a 90 day global period. 
It was inappropriate to bill CPT 99203 with the -25 modifier, as a decision was made to perform the procedure 
during the office visit. Separate billing and reimbursement cannot be allowed. 
 
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 99203-25 rendered on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 21, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says it cannot be determined 
how the member came to the servicing provider, whether the services were performed as billed, or whether the 
services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. Based on this information, we decided 
that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the testing provided on March 21, 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 cannot walk and need help transferring to your 
walker or to do the functions. The Plan denied your request. The Plan says the criteria for admission to the 
Acute Inpatient Rehabilitation setting have 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 documentation does not support necessity for an admission to an IRF. The 
complexity of your medical, rehabilitation, and nursing needs (combined complexity) does not require an acute 
hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our reviewer also 
found that your rehabilitation needs can be safely provided in an alternate and low intensity setting.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary for the 
enrollee. It could lead to an adverse outcome since everything she has tried has not worked for her. She could 
end up back in the hospital. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of a ventilator. 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that although the documentation is 
stating failure of BIPAP, the enrollee is noncompliant with home BIPAP and was treated in the hospital with 
average volume-assured pressure support (AVAPS). There is no arterial blood gas provided which shows 
worsening on BIPAP or AVAPS. Therefore, the enrollee does not have supportive documentation for a home 
ventilator from records provided. Hence, she does not meet requirements for a home ventilator with the 
information provided. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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. 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 is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more stable and appropriate for transfer. 
 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: 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 cannot stand up and transfer without maximum 
assistance, and you have very limited use of your left leg. You also say that you are not safe to discharge home 
safely, your right hand is damaged, and needs therapy as well. The Plan denied your request. The Plan says the 
IRF services requested 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 you are medically stable and do not need a physical medicine and rehabilitation 
physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs identified or 
documented. Our reviewer found that at the current functional level, you do not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. The documentation does not support necessity for admission to an IRF. The complexity of your medical, 
rehabilitation, and nursing needs (combined complexity) do not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our physician reviewer also found 
that your rehabilitation needs can be safely provided in an alternate and low intensity setting.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377), harness (E2313), and footplate 
extension (K0108). 
 You asked the Plan to pre-approve the electrical connection between the wheelchair controller and two or more 
motors, expandable controller, harness, and footplate extension. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
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 electrical connection between the 
wheelchair controller and two or more motors, expandable controller, harness, and footplate extension. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has adequate upper body strength to control the wheelchair through the 
standard power switches included in the base codes. The foot plate extensions have a code therefore may not be 
coded as K0108. 
 
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 electrical connection between the wheelchair controller and two or more 
motors, expandable controller, harness and footplate extension have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the electrical connection between the wheelchair controller and two or 
more motors (E2311), expandable controller (E2377), harness (E2313), and footplate extension (K0108).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 15, 2023, to 
February 13, 2023. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA. The 
Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied. The Plan says that although your appeal indicates that a NOA was submitted, none has been received 
by the Plan. 
 
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 NOA was not received by the Plan. 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 January 15, 
2023, to February 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from September 21, 2022, to 
October 20, 2022. 
 You asked the Plan to pay for home health care. You say that medically necessary services were provided for 
the enrollee. 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 September 21, 2022. The NOA was not received by the Plan until January 
30, 2023. 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 care provided 
from September 21, 2022, to October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480, 80307) and validity testing billed with 
code 83789 for date of service April 21, 2023.  
 
You asked the Plan to pay for drug testing and validity testing services. You say that these services were 
medically necessary and should be paid. The Plan denied your request. The Plan says code 83789 is not 
separately payable. In addition, the records provided do not detail the drugs requested for testing by the 
provider. Therefore, the services provided cannot be verified as medically necessary and requested by the 
enrollee's physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services at issue have not been met. Specifically, while the records provided do include a 
physician order, this order does not detail the specific drugs requested for testing in this case. Without this 
information, we cannot verify that the drugs tested were requested by the enrollees physician and were 
medically necessary. In addition, we find that the testing described by code 83789 is not separately payable. 
Therefore, we decided that the Plan does not have to pay for drug testing (G0480, 80307) and validity testing 
billed with code 83789 for date of service April 21, 2023.