Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator, any type, used with non-invasive 
interface (E0466) provided January 8, 2023. 
 
You asked the Plan to pay for the ventilator. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says under Medicare guidelines, the request 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. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document a diagnosis of chronic respiratory failure consequent 
to chronic obstructive pulmonary disease although no arterial blood gas studies are provided to support the 
diagnosis. The home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-
up rate. The records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this policy will be denied as not reasonable and 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pay for the home ventilator, any type, used with non-invasive interface (E0466) provided January 8, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D diagnostic testing (88361, 88312, 88305 and 
88112) provided on March10, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic testing. You say that you are requesting reconsideration of the 
claim, which was denied as experimental and investigational, for the standard surgical pathology procedures 
performed by your laboratory known as WATS 3D. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 WATS 3D diagnostic testing (88361, 88312, 
88305 and 88112) provided on March10, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 27, 2022, 
through October 6, 2022.  
 You asked the Plan to pay for the home health services. You say that this claim should be paid due to medical 
necessity.  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 1, 2022. The NOA was not received by the Plan until October 6, 
2022. 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 September 27, 2022, through October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213-25) provided on October 25, 2022. 
 You asked the Plan to pay for the office visit. You say that the service is supported. The Plan denied your 
request. The Plan says this code is included in the global day period of Current Procedural Terminology (CPT) 
code 20610. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the office visit. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The medical record includes documentation of Gelsyn-3 
injection, with evaluation and management service related to the injection performed. In this case, evaluation 
and management service would not be reported, and included in the global period for the injection service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213-25) provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204 rendered on December 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 99204 (1 Unit) remains 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 99204 is "Office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making. 
When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the provided records in this case 
document a comprehensive history with a chief complaint, an extended history of present illness, a review of 
all additional body systems and a complete past, family and social history. The records in this case document a 
comprehensive examination including a general multisystem examination or a complete examination of a 
single organ system. The records support a moderate level of decision making, as the records document 2 out 
of 3 of multiple diagnoses or management options (dementia, dysphagia, acid reflux, hypertension), a moderate 
amount and complexity of data reviewed (speech pathology report, modified barium swallow) and moderate 
risk of complication (moderate risk for aspiration, malnutrition, dehydration; high risk of aspiration 
pneumonia).  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99204 rendered on December 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: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
17, 2022, to December 1, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary for the enrollee.  
The Plan denied your request. The Plan says the services were no longer necessary for the enrollee.  
 
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 pay for 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 did not have documented skilled nursing or skilled therapy needs. Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs were custodial and could be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from November 17, 2022, to December 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve radiofrequency ablation (RFA) 
(64640 and 64624). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says  there is not enough evidence to show that this is safe and helpful.  
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient medical evidence to support the use of the Iovera procedure for knee pain. 
The request is deemed not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the genicular nerve radiofrequency ablation (RFA) (64640 and 64624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided from October 29, 2022, 
through October 31, 2022. 
 
You asked the Plan to pay for post-stabilization care. You say that the services were authorized and necessary.  
The Plan denied your request. The Plan says the emergency services were covered, and post-stabilization care 
can be rendered by network providers.  
 
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 post-stabilization care. Our physician 
reviewer found the review has determined that the treating physician did not document (in the physician notes, 
on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided from October 29, 2022, through October 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 28, 2022, to 
February 26, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required 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 January 28, 2022. The NOA was not received by the Plan until July 27, 
2022. 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 January 28, 2022, to February 26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99283 
for December 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99283 was billed with the incorrect modifier. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 0 identifies codes that describe physician services. Modifiers 26 & TC cannot be used with 
these codes. 
 
We looked at the file and Medicare rules. Procedure code 99283 has a PC/TC indicator of 0 and was billed with 
the -26 modifier. This code cannot be billed with this modifier. Therefore, we decided that the Plan does not 
have to pay for the emergency room (ER) services billed with code 99283 for December 22, 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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (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 that the enrollee does not meet the coverage criteria for this admission. The enrollee 
is medically stable and does not need physician supervision three times a week in an IRF. There are no acute 
rehab nursing needs identified or documented. At the current level of function, the enrollee does not need 
intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. There is no current medical complexity. The complexity of the enrollee's 
nursing, rehab, and medical, needs (combined complexity) does not require an acute hospital inpatient rehab 
stay with an interdisciplinary approach to rehabilitative care. Rehab needs can be provided in a lower intensity 
and alternate setting such as in in-home with services. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on November 16, 
2022, billed with codes 99304, 70450, 96376, and 96361. 
 
You asked the Plan to pay for the services as billed. You say that these codes should be paid. The Plan denied 
your request. The Plan says the codes that were denied are not separately payable under the Outpatient 
Prospective Payment System (OPPS). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99304 has a status indicator of B in the OPPS. This means it is not recognized and cannot be paid. Code 
70450 has a status indicator of Q3. This means that it is paid by a composite with other Q3 codes. This 
composite payment was made on code 72125, which is another Q3 code. 96376 has a status indicator of N, 
meaning that payment is always packaged with other services. Lastly, code 96361 is an add-on code to 96360. Since 96360 was not billed, no payment can be made for 96361. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient hospital services provided on November 16, 2022, billed with codes 
99304, 70450, 96376, and 96361.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80050, 85652 billed for date of service 
December 13, 2022.  
You asked the Plan to pay for procedure codes 80050, 85652. You say that your doctor ordered routine blood 
panels, which they do annually. You do not understand why the Plan decided not to pay for this. 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 80050 is not covered or paid for by Medicare. Procedure code 85652 has a Status 
Indicator of I on the Physician Fee Schedule. This means that procedure code 85652 is not valid for Medicare 
purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 80050, 
85652 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 80050, 
85652 billed for date of service December 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home physical therapy visits (G0151). 
 You asked the Plan to pre-approve home health services. You say that you disagree with the denial and request 
reconsideration. 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 the 
documentation does not support that you require additional skilled rehab services to provide treatment that is 
medically necessary. You do not require additional skilled rehab services to effectively provide treatment, care, 
and/or services in order to improve your condition, perform a maintenance program to maintain your condition 
and/or prevent deterioration.  You have been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The requested home health services are not medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home physical therapy visits (G0151).
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee has tolerated inpatient rehabilitation services and continues to 
improve with daily skilled nursing and/or skilled therapy services. The enrollee could benefit from continued 
services at the current level of care. The enrollee has made slow progress with therapy and there is no 
indication that a transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled 
rehabilitation services at the current inpatient rehabilitation facility or be stepped down to a lower level of care 
when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehabilitation 
facility.   
 
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.