Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
for the denial of an IRF admission. The Plan denied your request. The Plan says the service requested is not 
supported based on the records received.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 27, 2022, to 
December 22, 2022. 
 
You asked the Plan to pay for the home health services. You say that you have billed the required Federal 
Information Processing Standard (FIPS) codes. The Plan denied your request. The Plan says you did not bill the 
FIPS code data correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that value code 85 is defined "County Where Service 
is Rendered." This code is required for home health claims to appropriately calculate county-based rural add-on 
payment amounts.  
 
In this case, you billed FIPS codes of 85 and 61.  We agree that these are valid codes.  However, you failed to 
bill any value amounts for either of these FIPS codes.   Amounts are required to appropriately calculate any add-on payments that may be applicable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from November 27, 2022, to December 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on October 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 the ICD-10 diagnosis code F07.81 has code first instructions. 
 
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 find that CPT code 99285 is not supported in the medical record. Specifically, this emergency room code 
was billed with ICD-10 diagnosis code F07.81 as the primary diagnosis code. This diagnosis code is considered 
a "code first" code, and requires another diagnosis code to sequenced before it to show the underlying 
condition. 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 emergency room services (procedure code 
99285) rendered on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced care planning (procedure code 99497) rendered on 
June 24, 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 CPT 99497 is part of the primary procedure and not eligible 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. 
 
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 procedure report does not 
include any documentation of advance care planning for thirty minutes. This discussion was not included in the 
documentation submitted for review.  
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 advanced care planning (procedure code 99497) rendered on June 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation.  
You asked the Plan to pre-approve sacral nerve stimulation. You say that you would like to appeal the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for sacral nerve stimulation. 
 
The Plan must follow Medicare rules. Medicare rules say that sacral nerve stimulation is only covered for 
urinary incontinence when certain criteria are met.  Specifically, there must be evidence that you have 
undergone a trial of nerve stimulation with 50% improvement.  According to your medical records, no such 
trial has occurred. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sacral nerve stimulation have not been met. Therefore, we decided that the Plan does not have to 
pre-approve sacral nerve stimulation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing provided on January 19, 2023, billed 
with codes 87481, 87500, 87640, 87652, 87653, 87798, and 87798-91. 
 
You asked the Plan to pay for the urine PCR testing billed. You say that this claim should be processed as in-
network as these services were medically necessary. 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 Current Procedural Terminology (CPT) Manual 
assigns CPT codes to organ- or disease-oriented panels consisting of groups of specified tests. If all tests of a 
CPT-defined panel are performed, the provider/supplier shall bill the panel code instead of the individual 
components. 
 
 We looked at the file and Medicare rules. The urine PCR testing you billed as individual components was not 
billed with a single panel code as required. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR testing billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine PCR testing provided on January 19, 2023, billed with codes 87481, 87500, 87640, 87652, 
87653, 87798, and 87798-91.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code D62 
rendered from April 21, 2022, to April 22, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 DRG 467. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the reported hemoglobin level as reported did not impact care, require continued monitoring, or additional 
nursing care. It does not require an intervention or longer length of stay. Whether the enrollee had that level of 
anemia is unclear as it was only measured once, and not consistent with other clinical data.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code D62 rendered from April 21, 2022, to April 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy requirements were not met.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has not 
tried and failed the required drugs. There is no documentation provided indicating that the plans required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Climara. 
 
You asked the Plan to pre-approve Climara. You say that that the enrollee would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says self-administered drugs do not fall under 
Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Climara.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 1, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the psychotherapy was medically necessary. The 
Plan denied your request. The Plan says this provider type is not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on  
December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93623 and 93653 rendered on June 13, 
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 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 93623: 
 
Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for 
primary procedure)  
CPT 93653: 
 
Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, 
induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation 
of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular 
pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle 
recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow 
atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial 
focus or source of atrial re-entry 
 
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 procedure report does not 
include any documentation of either billed code. The services 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93623 and 93653 rendered on June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 2, 2022, to June 
9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
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 principal diagnosis code A41.9, described as sepsis, 
unspecified organism, and secondary diagnosis code R65.20, described as severe sepsis without septic shock. 
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 documentation does not support the billed codes. Our physician 
reviewer found that there was no laboratory or clinical evidence of sepsis. The review has determined that the 
documentation did not support A41.9 and R65.20.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 2, 2022, to June 9, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy, flexible; with endoscopic mucosal resection 
rendered on December 2, 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 CPT 45390 is part of the primary procedure and are ineligible 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. 
 
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 CPT 45390 is not separately 
reportable with biopsy, submucosal injection, snare or band ligation described by 45380, 45381, 45385, 45398 
for the same lesion. The procedure report does not include documentation to support billing CPT 45390 separately from CPT 45385. 
 
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 colonoscopy, flexible; with endoscopic mucosal resection rendered on December 2, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 You asked the Plan to pre-approve Simponi Aria. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Simponi Aria. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 30, 2022, billed 
with codes 81314, 81345, & 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 30, 2022, billed with codes 81314, 81345, & 81272.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia injections. 
 
You asked the Plan to pre-approve Prolia injections. You say that the enrollee has been on the medication and 
after recent scan results, they need to remain on it. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia injections. 
  
Benefits for Prolia injections may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 17110 and 99202 billed for date of service 
January 3, 2023.  
 You asked the Plan to pay for procedure codes 17110 and 99202. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 17110 and 99202 is 1. The MAI value for these codes is 2. You billed 2 
units each of these codes, exceeding the MUE. The file shows two separate claims were submitted, and the 
Plan paid for the first claim. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 17110 and 99202 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 17110 and 99202 billed for date of service January 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from May 5, 
2020, to May 18, 2020. 
 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 a corrected claim needs to be received. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that these services are not supported in the medical record. Specifically, the claim was not billed with 
the appropriate HIPPS codes. 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 skilled nursing facility 
(SNF) services rendered from May 5, 2020, to May 18, 2020.