Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for November 7, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 9, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 for 
November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services for date of service December 
8, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, this service was billed with a 
place of service 21 (inpatient); however, the documentation shows that the enrollee was in an outpatient 
hospital observation status for this date of service. Based on this information, we decided that Medicare rules 
for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan does 
not have to pay for the initial hospital care services for date of service December 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gabapentin (J8499). 
 
You asked the Plan to pre-approve Gabapentin (J8499). You say that Gabapentin (J8499) is needed for the 
enrollee. The Plan denied your request. The Plan says this is part of the self-administered drug exclusion list. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gabapentin (J8499).   
Benefits for Gabapentin (J8499) may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 You asked the Plan to pre-approve the home health services. You say that the services should be approved. 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 the home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the member is 
a 63-year-old female with a medical history including chronic back pain with spinal stenosis who underwent 
spinal surgery in April 2023. She was discharged home on 04/19/2023 in stable condition. The documentation 
available for review indicates the member was able to accomplish functional mobility independently at the time 
of hospital discharge. She was able to ambulate up to 400 feet. There is no indication that the member has a 
feeding tube, parenteral medications or complex wound care issues. There is no indication that the member had 
any recent medication changes or hospitalizations. There has not been a recent decline in function and the 
member has been medically stable. 
 
the documentation doesnt support that the member requires additional skilled rehab services to provide 
treatment that is medically necessary. The member does not require additional rehab services to effectively 
provide treatment, care, and/or services in order to improve the members condition, perform a maintenance 
program to maintain the members condition and/or prevent deterioration.  The member has 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 the home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport provided on November 7, 
2022. 
 
You asked the Plan to pay for the non-emergent ambulance transport. You say that the medical records 
provided support the need for the ambulance transport. The Plan denied your request. The Plan says the 
transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance transport. Our 
reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the 
transportation via ambulance from the hospital discharge was not medically necessary. The enrollee did not 
require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car, taxi) without endangering the enrollee's condition. 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 non-emergent ambulance transport have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergent ambulance transport provided on November 7, 
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 should transfer to an IRF to gain 
strength. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF care. 
 
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 require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that the enrollee would meet criteria for admission to an IRF. 
There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status. The enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 2, 2022, to 
January 3, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue have been billed 
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 the location where services were provided must 
always be reported along with the first visit reported on the claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the first home health visit reported was 
January 2, 2022, but there is not a Q-code provided to say where the service was performed. Therefore, we 
decided that the Plan does not have to pay for home health services provided from January 2, 2022, to January 
3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on October 26, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on October 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRa molecular signature test (81479) provided June 
23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denial over coverage and payment for PrismRa Testing. The Plan denied your request. The Plan says this 
service is determined to be considered to be experimental or investigational. 
 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 the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has seronegative rheumatoid arthritis.  The 
PrismRa molecular signature test 81479 has been requested to establish possible resistance to tumor necrosis 
factor inhibitor (TNFi) therapies. 
 
Per the reviewed literature, the use of signature molecular testing has been investigated for predicting response 
to TNFi therapy using RNA sequencing and gene expression data. The available literature addresses a single 
test, the PrismRA, developed to assist providers in therapy selection by identifying individuals that are 
predicted to be unlikely to respond to TNFi therapy. The American College of Rheumatology (ACR) 2021 RA 
treatment guideline strongly recommends initiating TNFi therapy when disease activity is moderate or high 
despite disease-modifying anti-rheumatic drugs (DMARDs), with the recommendation to alter therapy if 
needed due to comorbidities (Fraenkel, 2021). The results of the test are sorted into categories (very high, high, 
moderate, no signal) that are purported to predict the likelihood of nonresponse to TNFi therapy. The ACR 
provides no guidance regarding molecular signature testing. The integration of this test within standardized 
endorsed treatment guidelines is needed to demonstrate clinical utility. The review has determined that the 
items/services at issue in this case are 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the PrismRa molecular signature test (81479) provided June 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99223 billed for date of service January 10, 2023. 
 
You asked the Plan to pay for code 99223. You say that these services were provided to the member, so this 
claim should be paid. The Plan denied your request. The Plan says that code 99223 is billed incorrectly.  The 
Plan says that because the Place of Service code billed (21) is an outpatient hospital, you need to bill a 
corresponding Initial Observation Care code (99218-99220) instead. 
 
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 Plan's sole rationale for denial is that another code should have been used to bill for 
observation services.  This is not true.  The definition of code 99223 is now defined as "Initial hospital 
inpatient or observation care". This means that starting on January 1, 2023, observation care should be billed 
using the same codes as inpatient hospital care. The services in dispute occurred after this change.    
 
Based on this information, we decided that Medicare rules for coverage of code 99223 have been met. 
Therefore, we decided that the Plan has to pay for code 99223 billed for date of service January 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC genetic testing panel provided on July 
25, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC genetic testing. You say that this testing is Medicare-
covered and should be paid. The Plan denied your request. The Plan says the unique identifier was not reported 
on the claim as required. 
 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. While the unique identifier was located on the claim form, the DEX 
Diagnostic Exchange lists this test as not covered by Medicare. Based on this information, we decided that 
Medicare rules for coverage of the DecisionDx-SCC genetic testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the DecisionDx-SCC genetic testing panel provided on July 25, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from December 3, 2022, to December 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that diagnosis code 
Z68.32 was not billed with a POA indicator. 
 
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 argues that diagnosis code Z68.32 was not billed with a POA indicator. 
However, diagnosis code Z68.32 is on the POA exempt list, and as such, does not require a POA indicator for 
payment to be considered. Without supporting documentation, the Plans denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the services provided from December 3, 2022, to December 
12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 billed for date of service August 29, 
2022. 
 You asked the Plan to pay for procedure code 27335. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 27335 is bundled into payment for code 27447. 
 
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 27335 
is a column II code to column I code 27447. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 27335 billed for date of service August 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the calcium-sensing receptor (CASR) gene sequencing analysis 
(81405). 
 
You asked the Plan to pre-approve the genetic testing. You say that that measurement of the calcium sensing 
receptor gene (CASR) is not limited to patients with cancer. The Plan denied your request. The Plan says that 
the request does not meet the Medicare criteria as the enrollee does not have a personal history of cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 genetic testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the test is reasonable since if the enrollee has familial hypocalciuric hypercalcemia (FHH), 
which is suggested by the low urine calcium in this enrollee, then surgery would not be necessary. Otherwise, if 
the enrollee has hyperpara then surgery is indicated as the enrollee has a compression fracture. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pre-approve the calcium-sensing receptor (CASR) gene sequencing analysis (81405).  
 
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: 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 the enrollee requires an LTACH level of 
care and is stable for discharge. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary. 
 
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 documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH.  The enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility.  The requested treatments are not medically necessary at the LTACH level of care.  The enrollee has improved medically but continues to require care at an acute hospital.  
She can receive further care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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.