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 if admitted to a lower level of care, the enrollee 
would not receive the aggressive therapy and medical management that is necessary to achieve their goal of 
returning home and reintegrating into the community. 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 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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services at a lower 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft (20930). 
 
You asked the Plan to pre-approve allograft. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Osteopromotive allograft is experimental in 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 allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311).
You asked the Plan to pre-approve an electronic connection. You say that the item is medically necessary. The
Plan denied your request. The Plan says that the item is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection. Our Medical Director states that the documentation supports that your upper extremity strength and
function appear to be adequate to operate the power options using their own switches. Our Medical Director
found that your condition does not meet criteria for coverage of an electronic connection.
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 electronic connection have not been met. Therefore, we decided that the Plan
does not have to pre-approve an electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 billed for date of service July 12, 
2023. 
 You asked the Plan to pay for procedure code 97598. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 97598 is bundled into payment for code 11042. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 97598 
is a column II code to column I code 11042. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 97598 billed for date of service July 12, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the therapy should be covered because 
you have degenerative issues, past injury, and recently had surgery. The Plan denied your request. The Plan 
says that the therapy is not medically reasonable and necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy is not generally accepted as 
specific and effective therapy for your condition beyond what was approved by the Plan. The records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge, and judgment of a qualified therapist is not required to establish, design, and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. The documentation 
notes normal cervical, trunk, lower extremity range of motion. You have normal upper and lower extremity 
strength. The documentation from September 6, 2023, notes that you have had extensive therapy for this 
condition. You have pain but do not have significant range of motion or strength deficits that would require 
additional skilled therapy.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 30 physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 6, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildups (D2950 x 2), removal of residual tooth 
roots (D7250) and bone replacement graft for ridge preservation (D7953 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee meets the criteria for coverage. 
The Plan denied your request. The Plan says these services are either not covered benefits or your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D2950 was exhausted on dates of service August 9, 2022, and August 23, 2022. 
Additionally, D7250 and D7953 are not covered under any circumstance. Therefore, we decided that the Plan 
does not have to pre-approve the core buildups (D2950 x 2), removal of residual tooth roots (D7250) and bone 
replacement graft for ridge preservation (D7953 x 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS Oral Brush CDx biopsy test (88361, 88312, 
88305, 88104) provided February 22, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that WATS 3D is a medically necessary service 
for this enrollee since it is a proven superior method of acquiring and analyzing esophageal tissue verses the 
routine forceps biopsy alone. The Plan denied your request. The Plan says this test is considered experimental 
and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. The clinical value and effectiveness of the WATS Oral Brush CDx 
Biopsy test in the setting of an unchanged chronic oral plague lesion has NOT been demonstrated in the peer-
reviewed literature. Based on this information, we decided that Medicare rules for coverage of the laboratory 
service have not been met. Therefore, we decided that the Plan does not have to pay for the WATS Oral Brush 
CDx biopsy test (88361, 88312, 88305, 88104) provided February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service March 10, 
2023, to April 7, 2023. 
 
You asked the Plan to pay for procedure code 99212. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99212 is bundled into payment for code 97813. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99212 
is a column II code to column I code 97813. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99212 billed for date of service March 10, 2023, 
to April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the lift chair (E1399) purchased March 31, 2021. 
 
You asked the Plan to reimburse you for the lift chair. You say that you have made several attempts to get 
reimbursed and during this process you were told you are too late filing this claim. You keep getting the run 
around on the lift chair claim. The Plan denied your request. The Plan says the claim was received after the 
timely filing limitation and the claim must be submitted to the primary insurance carrier 
 The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lift chair was not filed until March 31, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to reimburse you for the lift chair (E1399) purchased March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 13, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2023, billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 81306-59, 81328-59, 
81335-59, 81238-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have attached additional documents 
to support the claim. 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 
May 31, 2023, billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-
59, 81306-59, 81328-59, 81335-59, 81238-59.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH 
services requested do not meet the requirements for approval.  
 
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 was hospitalized for 3 months, discharged to a rehabilitation facility, 
and has now been re-hospitalized for sepsis. The enrollee has a number of serious, ongoing conditions, 
including the inability to dialyze safely outside the Intensive Care Unit setting, rendering the enrollee not a candidate for an LTACH 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 12, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service July 7, 2023.  
 
You asked the Plan to pay for procedure code G0481. You say that this service is medically necessary. The 
Plan denied your request. The Plan says payment for code G0481 is bundled into payment for code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code G0481 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0481 billed for date of service July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87529, 87640, 87798, 87491, 87591, 
and 87661 billed for date of service May 4, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a Medicare covered service. The Plan 
denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The file shows that a wound panel test and a vaginitis panel test was ordered. In this case, we have confirmed 
that codes 87491, 87591, and 87661 are column II codes to column I code 87801. These codes have not been 
billed with an appropriate modifier to bypass the edit. There are insufficient records to show that codes 87481, 
84529, 87640, and 87798, billed with the -59 modifier were separate and distinct services. The case file does 
show that the Plan made multiple attempts to obtain additional information, but none was provided. Based on 
the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87481, 87529, 87640, 87798, 87491, 87591, and 87661 billed for date of 
service May 4, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on January 14, 2022, to January 21, 
2022. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the outpatient services provided do not meet 
preadmission bundling requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient diagnostic services furnished to a 
beneficiary more than 3 days preceding the date of the beneficiarys admission to the hospital, by law, are not 
part of the payment window and must not be bundled on the inpatient bill with other outpatient services that 
were furnished during the span of the 3-day payment window. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The records show that the claim in dispute 
was billed for dates of service starting on January 14, 2022. This is more than 3 days preceding the January 18, 
2022, date of admission.  Therefore, we decided that the Plan has to pay for practitioner services provided on 
January 14, 2022, to January 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.