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's health will be put at risk if 
LTACH services are not rendered. The Plan denied your request. The Plan says the enrollee does not meet all 
the requirements for admission 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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for breast cancer index testing (81518) billed for date of service May 2, 
2023. 
 
You asked the Plan to pay for breast cancer index testing. You say that this test was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says that this test was submitted with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of breast cancer index testing have been met. Specifically, the specimen in question was part of a 
cancerous tumor which would have been collected by a surgeon in a medically necessary and appropriate 
hospital stay. The test in question was performed after discharge from this stay. This means the reported date of 
service should reflect the date the test was performed and reported. In this case, the test was reported/performed 
on May 2, 2023. Therefore, we decided that the Plan has to pay for breast cancer index testing (81518) billed 
for date of service May 2, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99348 provided on March 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for code 99348. You say that other codes have not required authorization. The Plan 
denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for code 99348 provided on March 10, 2023, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary, and the 
enrollee's medical needs will not be managed well at a lower level of care.  The Plan denied your request. The 
Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care 
such as a skilled nursing facility.  
 
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 enrollee was admitted for weakness. The enrollee's medical problems are stable, 
and there are no complex nursing or rehabilitation needs. The enrollee does 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care is not safe, sufficient, or 
equipped to address the enrollee's needs related to their comorbidities and allow the enrollee to gain a higher 
level of functioning to improve their quality of life. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee 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 this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hearing aids. 
 
You asked the Plan to pre-approve the hearing aids. You say that you are having problems with your left 
hearing aid. You say it has been five years since you replaced your left hearing aid and three years for your 
right hearing aid. The Plan denied your request. The Plan says the hearing aids are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve the hearing aids.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx - Melanoma testing (81529) provided on March 
10, 2023. 
 
You asked the Plan to pay for DecisionDx testing. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says the enrollee does not meet the criteria for medical 
necessity of this test. 
 
The Plan follows Medicare rules. Medicare rules say that that molecular diagnostic tests used to assist in risk 
stratification of melanoma patients are covered when the patient has a personal history of melanoma and either 
has Stage T1b and above or has T1a with documented concern about adequacy of microstaging. 
 
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 DecisionDx testing. Our reviewer says that 
DecisionDx testing was not medically necessary. Our physician reviewer found the provided records in this case document the patient has a T1a melanoma without documented concern about the adequacy of 
microstaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx testing have not been met. Therefore, we decided that the Plan does 
not have to pay for DecisionDx - Melanoma testing (81529) provided on March 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from acute inpatient 
rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
an IRF admission 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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
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 IRF admission and 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(x3) billed  with the XU modifier for date of service March 2, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798 and 87801(x3). You say 
that these services were necessary and are documented in the medical record. The Plan denied your request. 
The Plan says these codes are not supported as they were reported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -XU modifier if 
the service billed with the modifier indicates an Unusual Non-Overlapping Service.  
 
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 procedure codes 87150, 87481, 87641, 87653, 87798 and 87801(x3). Our reviewer says that the use of the XU modifier for codes procedure codes 
87150, 87481, 87641, 87653, 87798 and 87801(x3) is not supported by the medical record. Our physician 
reviewer found although you reported the XU modifier for these codes, the laboratory report does not include 
documentation to support an unusual non-overlapping service from code 87801. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653, 87798 and 87801(x3) 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(x3) billed  with the XU modifier for date of service March 2, 2023.
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(x3) billed with the XU modifier for date of service January 25, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798 and 87801(x3). You say 
that these services were necessary and are supported as billed. The Plan denied your request. The Plan says 
these codes are not supported in the medical record as reported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -XU modifier if 
the service billed with the modifier indicates an Unusual Non-Overlapping Service.   
 
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 procedure codes 87150, 87481, 87641, 87653, 87798 and 87801(x3). Our reviewer says that the use of the XU modifier for codes 87150, 87481, 
87641, 87653, 87798 and 87801(x3) is not supported by the medical record. Our physician reviewer found 
although you reported the XU modifier for these codes, the laboratory report does not include documentation to 
support an unusual non-overlapping service from code 87801. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653, 87798 and 87801(x3) 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(x3) billed with the XU modifier for date of service January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guidance urinary tract infection (UTI) panel testing (87481, 
87500, 87511, 87640, 87653, 87798 and 87801) provided on March 6, 2023. 
 
You asked the Plan to pay for the Guidance UTI panel. You say that this test was appropriate and was 
requested by the enrollee's physician. The Plan denied your request. The Plan says this test was 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 pay for the Guidance UTI panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation is to why a basic urinalysis with reflex culture was 
insufficient. 
 
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 Guidance UTI panel have not been met. Therefore, we decided that the Plan 
does not have to pay for Guidance urinary tract infection (UTI) panel testing (87481, 87500, 87511, 87640, 
87653, 87798 and 87801) provided on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance Urinary Tract Infection (UTI) panel (87481, 
87500, 87511, 87640, 87653, 87798 and 87801) provided on April 13, 2023. 
 
You asked the Plan to pay for the Guidance UTI panel. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says this panel was not medically necessary and exceeded 
the enrollee's needs. 
 
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 pay for the Guidance UTI panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation is to why a basic urinalysis with reflex culture was 
insufficient. 
 
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 Guidance UTI panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guidance Urinary Tract Infection (UTI) panel (87481, 87500, 87511, 87640, 
87653, 87798 and 87801) provided on April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480 and 80307) billed for date of service 
March 2, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says one definitive and one 
presumptive drug testing service may be billed per enrollee per date of service to any provider. The provider in 
this case was already paid for codes G0483 and 80307 from a different claim on October 27, 2022. The 
additional codes for these services cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that only one code from the 80305-80307 range and 
only one code from the G0480-G0483 (and G0659) range may be reported and paid to any provider per date of 
service per enrollee. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, the record shows that this same provider has already 
been paid for one code from each of these code ranges (G0483 and 80307) on a separate claim for the same 
date of service and enrollee. Therefore, we decided that the Plan does not have to pay for drug testing (G0480 
and 80307) billed for date of service March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 87481, 87653, 87798, and 
87801 for date of service January 31, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 87801 is not supported by the medical record.  The 
Plan also says that codes 87481, 87653, 87798 are not separately payable and modifier XU use is 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 the lab services. Our reviewer says that lab services billed 
with codes 87481, 87653, 87798, and 87801 are not supported by the medical record.  Our reviewer found for codes 87481 and 87653, you reported the procedure with appended modifier XU to indicate an unusual non-
overlapping service to bypass the NCCI Edit. However, the medical record does not include documentation to 
support what tests are being billed with panel codes 87798 and 87801.  Therefore, this procedure and modifier 
cannot be verified.  
 
For codes 87798 and 87801, the laboratory report does not include documentation to support tests being 
reported with these procedure codes, and therefore these codes 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 the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services billed with codes 87481, 87653, 87798, and 87801 for date of service January 31, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve the PNS. You say that the enrollee is experiencing severe pain and has 
exhausted other treatment modalities. The appellant says the PNS is covered for chronic pain conditions.  The 
Plan denied your request. The Plan says the PNS is not medically necessary. The Plan says that the enrollee has 
been screened by a mental health professional.  
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 PNS. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a diagnosis of left leg causalgia. Our doctor found that the diagnostic Budapest criteria 
of complex regional pain syndrome (CRPS) and the Spinal cord stimulation (SCS) reprogramming trials are not 
documented. The use of a Peripheral Nerve Stimulator at the same time of a Spinal Cord Stimulator, is not 
consistent with clinical practice guidelines. Therefore, the request is not medically reasonable and 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 the PNS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the peripheral nerve stimulator (PNS).