Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 4, 2023, to 
May 3, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that a NOA must be submitted using the first date of the period 
of care as the admission date. Subsequent claims must report this date as the admission date in order for the 
claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date of care as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 4, 2023, to May 3, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation (64624). 
 
You asked the Plan to pre-approve a genicular nerve ablation. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary because the literature does not support 
that this procedure is safe and effective and is the accepted standard of medical practice for osteoarthritis. 
 
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 a genicular nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental and investigational procedure at this 
time. It is the subject of ongoing clinical trials.  
 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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve ablation (64624).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 3, 
2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 19, 2022, billed 
with codes 81226, 81240, 81241 and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 19, 2022, billed with codes 81226, 81240, 81241 and 81328.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 24, 2022, to 
November 22, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary 
and should be paid. 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 October 24, 2022. The NOA was not received by the Plan until January 6, 
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 services provided 
from October 24, 2022, to November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service April 24, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says the service is not separately billable. 
 
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 J3490 was billed for drug Bupivacaine. This is a local anesthetic, which is not 
separately billable. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 
billed for date of service April 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 25, 2022, to 
July 24, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary 
and should be paid. 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 April 26, 2022. The NOA was not received by the Plan until January 16, 
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 the home health services 
provided from June 25, 2022, to July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92626-59 billed for date of service 
September 2, 2022.  
 
You asked the Plan to pay for procedure code 92626-59. You say that you billed this code with modifier 59, so 
separate payment should be allowed. The Plan denied your request. The Plan says payment for code 92626-59 
is bundled into payment for code 92592. 
 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 
92626-59 is a column II code to column I code 92592 with a modifier indicator of 0. This means that appended 
modifiers are not permitted to allow for separate payment of the code. The column II 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 92626-59 billed for date of service September 2, 2022.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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, falls, back pain and hypercalcemia. Medical 
problems are stable. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 16, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-
network 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 continuous positive airway pressure (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 the home ventilator. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found the enrollee could be treated with a 
BiPAP machine with AVAPS capability and failure of such a device has not been documented. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you require 10 additional physical 
therapy visits. The Plan denied your request. The Plan says the requested services are not reasonable and 
necessary, and the health plan has no contractual obligation to cover these services. 
 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 you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. 
 
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 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466), and humidifier (E0562). 
 
You asked the Plan to pre-approve a home ventilator and humidifier. 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. 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.  
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 and humidifier. Our 
reviewer says that the enrollee does not need these items. Our physician reviewer found the enrollee could be 
treated with a BiPAP machine with AVAPS capability and failure of such a device has not been documented. 
 
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 and humidifier have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a home ventilator (E0466), and humidifier (E0562).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says admission to an LTACH does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable at this time and 
requires additional acute care services that can safely be administered at the current facility until the enrollee is 
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 it would not be clinically advantageous at this time. Completion of 
treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 29, 2022, to 
July 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was sent and 
acknowledged by the Plan. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 29, 2022, to July 
28, 2022.  
 
Please note that it appears you may have submitted a corrected claim for these services.  Our decision is based on the 
Plans denial of your original claim.  Any questions regarding your corrected claim will need to be sent to the Plan 
directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the need for IRF 
admission. The Plan denied your request. The Plan says based on the available information, admission to IRF is 
not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours of rehabilitative services and regular physician 
evaluation. The enrollee's needs can be met at a lower level or 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 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 October 11, 2022, to 
October 28, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted a correct NOA. 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 October 11, 2022. The NOA was not received by the Plan until January 13, 
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 services provided 
from October 11, 2022, to October 28, 2022.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 worsening right sided weakness. Medical problems are 
stable. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.