Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement, and related services provided on November 16, 
2022. 
 
You asked the Plan to pay for debridement, and related services. You say that this is supported in the records. 
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 debridement, and related 
services provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99213 for date of service October 24, 
2022. 
 
You asked the Plan to pay for the office visit coded 99213. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says this service is included in the global surgery period of code 64561. 
 
The Plan must follow Medicare rules. Medicare rules say that when a surgery is performed, certain services are 
included in the price of the surgery itself and are not separately payable. 
 
 
 We looked at the file and Medicare rules. Review of the file shows that surgery procedure 64561 was provided 
on October 19, 2022. Code 64561 has a global surgery value of 10 days. Code 99213 was billed within the 
global surgery period of procedure 64561 without an appropriate modifier. This means code 99213 is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
office visit coded 99213 have not been met. Therefore, we decided that the Plan does not have to pay for the 
office visit coded 99213 for date of service October 24, 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 the enrollee is still an acute patient and meets acute 
rehab criteria. The Plan denied your request. The Plan says the enrollee does not have a complex medical 
diagnosis and does not require supervision by a rehabilitation physician.  
 
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 treatment by multiple therapies. While the medical 
record supports a need for physical 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service February 19, 2021. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the screening test is not a covered benefit. 
 
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 looked at the file and the rules. The panel testing was not billed with a single code as required. The records 
do not show that the testing was ordered for a specific medical condition. This testing is not covered for 
screening services. 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 panel testing billed 
for date of service February 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code 93970. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
  We find that CPT code 93970 is not supported. Specifically, code 93970 has been billed with the modifier 
"GZ," indicating that the service at issue is not reasonable and necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 93970 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 93970 billed for date of service November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records do not show that you suffer from diabetic foot disease or wear a leg brace. Although orthotics may 
be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. 
Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and inserts.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care services provided on October 13, 2022. 
 
You asked the Plan to pay for emergency care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this provider is not enrolled in Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that a provider must be enrolled in the Medicare 
program to receive payment for covered items or services. Medicare rules state that freestanding emergency 
departments were able to temporarily enroll in Medicare during the COVID-19 public health emergency 
(PHE). 
 
We looked at the file and Medicare rules. This provider was not enrolled in Medicare for the date of service in 
question; therefore, the provider is not eligible for payment. Based on this information, we decided that 
Medicare rules for coverage of emergency care have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency care services provided on October 13, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient psychiatric hospital services provided on December 10, 2022, 
to January 9, 2023. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that the enrollee could safely be treated in a less 
restrictive level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the inpatient admission was medically necessary. Our physician reviewer found the enrollee 
does meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of 
January 5, 2023, forward and could not have been treated in a lesser restrictive setting as he was found to be 
psychotic, responding to internal stimuli and preoccupation requiring active treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient psychiatric hospital services provided on December 10, 2022, to January 
9, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 15, 2022, 
to December 6, 2022. 
 You asked the Plan to pay for the home health services. 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 September 16, 2022. The NOA was not received by the Plan until March 8, 
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 November 15, 2022, to December 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network (OON) inpatient hospital services provided on November 15 through November 22, 2021.

You asked the Plan to pay for the OON inpatient hospital services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says there were multiple in-network facilities in close proximity that could have treated the enrollee.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 OON inpatient hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the provided documentation describes the enrollee as a 61-year-old female who presented with sudden fecal incontinence, chest pain, and abdominal pain following a recent motor vehicle accident (MVA.) She was started on epidural pain control medication, antibiotics for suspected pneumonia, fluids. Vitals were stable. She was able to ambulate. She revealed taking Percocet following accident. Workup was unremarkable or showed only minimal abnormal findings. She was accepted to trauma center for evaluation. There was no mention in the provided documentation from these dates that the enrollee was at any time not stable for transfer to an in-network hospital/physician. In the emergency department on November 15, 2021, around 13:28, the enrollee appeared to be stable enough for 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 OON inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for out of network (OON) inpatient hospital services provided on November 15 through November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 10, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for podiatry services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for podiatry services provided on January 10, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  Guardant Reveal test (81479) provided December 2, 2022. 
 
You asked the Plan to pay for  Guardant Reveal test. You say that you provide the Guardant Reveal molecular 
diagnostic test at the rest of the ordering physician. The Plan denied your request. The Plan says this service is 
considered experimental and investigational as it there is insufficient evidence in its safety and efficacy. 
 
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. Per DEX Diagnostics Exchange, Guardant Reveal is not covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of Guardant Reveal test have not been met. Therefore, we decided that the Plan does not have to pay for  Guardant Reveal test (81479) 
provided December 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services billed for date of service August 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes were billed correctly. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the lab services were provided while the enrollee was in a covered skilled nursing facility stay. 
The claim was not billed with the correct place of service code. 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 services billed for date of service August 8, 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 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 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 at this time and per the records submitted at this juncture, IRF admission is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that you were admitted to the acute hospital for C2-T2 laminectomy to treat cervical stenosis on June 27, 
2023. You tolerated the initial procedure well with noted complication of small wound dehiscence and are 
awaiting IRF placement. The treating MD, occupational therapist (OT), and physical therapist (PT) specifically 
recommended IRF placement to optimize your balance, mobility, strength, ADL independence and ensure 
proper medical management of post-op wound and pain among other issues. Per Medicare Benefit Policy 
Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall significantly complies with the various 
documentation requirements for IRF admission (e.g., as best summarized by PT evaluation on July 2, and OT 
evaluation on June 28). Indeed, there is no doubt that the complexity of your presentation so soon after this 
major surgery requires active and ongoing multi-disciplinary care to ensure you have a prompt return to PLOF 
and prevent avoidable complications. There is every reason to believe that you can participate and benefit at 
Medicare required levels. Therefore, the requested inpatient rehab facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital evaluation and management (EM) services 
provided on July 14, 2022, and July 15, 2022.  
 
You asked the Plan to pay for the EM services. You say that these services should be paid.  The Plan denied 
your request. The Plan says this was not billed correctly to report services performed by students or residents.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation 
to support that payment is due. Services done in part by students or residents must be billed with modifier GC.  
 We looked at the file and Medicare rules. The taxonomy code listed on the claim is for a student/resident. The 
claim is not billed with modifier -GC. There were no records submitted to support that the services were not 
performed in part by a student/resident. Based on this information, we decided that Medicare rules for coverage 
of the EM services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital 
evaluation and management (EM) services provided on July 14, 2022, and July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 16, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx for Prostate Cancer (81551) provided on 
March 9, 2023. 
 
You asked the Plan to pay for ConfirmMDx for Prostate Cancer. You say that this test was medically necessary 
and is a covered service under Medicare. The Plan denied your request. The Plan says the criteria for coverage 
of this test are not 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 pay for ConfirmMDx for Prostate Cancer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records show that the biopsy on March 9, 2023, shows atypia and a 
repeat biopsy will need to be performed regardless of the ConfirmMDx results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ConfirmMDx for Prostate Cancer have not been met. Therefore, we decided 
that the Plan does not have to pay for ConfirmMDx for Prostate Cancer (81551) provided on March 9, 2023.