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

 
We decided that the Plan does not have to pre-approve 13 home physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation shows that the enrollee has functional impairments but does not show that they are 
home bound thus the records do not show that skilled therapy services are required in the home setting to 
effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 home physical therapy visits.
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 enrollee needs intensive rehab because any lower 
care level would prolong and worsen their condition. The Plan denied your request. The Plan says the IRF 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's 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 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 the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on January 31, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
January 31, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on September 8, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that this service is not paid separately when inpatient. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan hasnt supplied any evidence that the enrollee was inpatient, and they 
havent addressed that the records show that the enrollee was transported from their home to the hospital. 
Therefore, we decided that the Plan has to pay for the ambulance services provided on September 8, 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 6, 2022, billed with 
procedure code 73560-26-50. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. The procedure code assigned must 
match the diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. Procedure code 73560-26-50 was billed with 
diagnosis codes M17.11 and M17.12 which are not appropriate for the billed procedure. Therefore, we decided that the Plan does not have to pay for imaging services provided on December 6, 2022, billed with procedure 
code 73560-26-50.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service April 12, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and Medicare rules. Review of the file shows that surgery procedure 62323 was provided 
on the same date of service. Code J3490 has a global surgery value of 00 days. Code J3490 was billed within 
the global surgery period of procedure 62323 without an appropriate modifier. This means code J3490 is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of code 
J3490 have not been met. Therefore, we decided that the Plan does not have to pay for code J3490 for date of 
service April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. 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 magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or foraminal stenosis. The cause of the back pain not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory genetic testing (code 81455) provided on 
January 26, 2023. 
 
You asked the Plan to pay for the testing. You say that the service was deemed medically necessary by the 
enrollee's physician. The Plan denied your request. The Plan says the claim has not been billed with appropriate 
diagnosis codes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate diagnosis code(s). Diagnosis codes with an Excludes1 note 
cannot be billed together. 
 
In this case, the CPT Code 81455 has not been correctly billed. Specifically, diagnosis code D46.Z (other 
myelodysplastic syndromes) and C93.10 (chronic myelomonocytic leukemia) were reported together. The ICD-
10-CM files show these diagnosis codes as having an Excludes1 note. Based on this information, we decided 
that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory genetic testing (code 81455) provided on January 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T6 kyphoplasty (22513). 
 You asked the Plan to pre-approve T6 kyphoplasty. 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. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 T6 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the computed tomography (CT) scan 
corroborated a committed fracture involving the T6 vertebral body with no significant displacement, likely 
acute to subacute. She presented non-hospitalized with moderate to severe pain she rated at 8/10. However, 
detailed documentation regarding a progression of the body height loss, greater than 25% vertebral body height 
loss, kyphotic deformity, or a severe impact on her daily activities is not evident. Moreover, there is CT 
corroboration of potential other causes of low back pain. Therefore, the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T6 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T6 kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 for date of service February 8, 2023. 
 
You asked the Plan to pay for procedure code 99215. 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. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99215 is not payable as billed. Specifically, code 99215 was billed with diagnosis codes 
M48.56XD (Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture 
with routine healing) and M80.00XD (Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing). These two diagnosis codes should not be billed 
together. Based on this information, we decided that Medicare rules for coverage of procedure code 99215 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99215 for date 
of service February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says your benefit for crowns has already been exhausted. The core buildup 
is not a covered service. 
 
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 the requested crown has been exhausted. The core buildup is not covered under your 
plan. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and a core buildup 
(D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 for date of service February 21, 2022. 
 
You asked the Plan to pay for procedure code 95822. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
We find that CPT code 95822 is not supported in the medical record. Specifically, the documentation shows 
that the EEG was performed during surgery. There is a more appropriate code to be billed for the services 
rendered.  
 Based on this information, we decided that Medicare rules for coverage of procedure code 95822 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 95822 for date of service 
February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service January 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided as requested. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the lab testing billed for date of 
service January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92623 for date of service December 2, 2022. 
 
You asked the Plan to pay for procedure code 92623 . You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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. 
 
In this case, the CPT Code Manual definition of code 93623 is programmed stimulation and pacing after 
intravenous drug infusion (List separately in addition to code for primary procedure). 
 
We find that CPT code 93623 is not supported in the medical record. Specifically, this code should not be 
reported for injections of a drug with stimulation and pacing following an intracardiac catheter ablation 
procedure to confirm adequacy of the ablation. Therefore, this code is not supported. Based on this 
information, we decided that Medicare rules for coverage of procedure code 92623 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 92623 for date of service 
December 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service October 26, 2022. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical 
records only include report for 11 drug classes. That means 22 or more drug classes are not supported. Based 
on this information, we decided that Medicare rules for coverage of code G0483 have not been met. Therefore, 
we decided that the Plan does not have to pay for code G0483 for date of service October 26, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for  the radiology services provided on August 21, 2022. 
 
You asked the Plan to pay for  the radiology services. You say that the service should be covered. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan hasnt provided a valid denial reasoning or any records to support the 
denial. The Plans EOC clearly states the enrollee does not need prior authorization. Therefore, we decided that 
the Plan has to pay for  the radiology services provided on August 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.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to hold you harmless for skilled nursing facility (SNF) services after March 30, 
2023. 
 
You asked the Plan to hold you harmless for SNF care. You say that you want to appeal the Plan's decision to 
end your SNF care on March 30, 2023. You were sick with COVID-19 while at the facility, and you were not 
able to receive the full level of restorative services while you were there. The Plan denied your request. The 
Plan says that the claim for SNF care provided on February 10, 2023, was denied correctly due to a billing 
issue and you are not liable for that claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, this request was clearly regarding discontinuation of care for SNF 
services after March 30, 2023, which was declared by the Plan in a Detailed Explanation of Non-Coverage 
dated March 28, 2023. However, the Plan has provided no additional review for whether the discontinuation 
was appropriate or not. Instead, the Plan reviewed a previous claim for which you were not liable. The Plan has 
failed to substantiate their denial of continued coverage in an appeal. Therefore, we decided that the Plan has to 
hold you harmless for skilled nursing facility (SNF) services after March 30, 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.