Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital 
currently because of the kidney function is worsening. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 a delay in decision for an acute rehabilitation stay 
will jeopardize their chance for a full recovery. The enrollee will clearly benefit from acute rehab to optimize 
their level of function prior to returning home. 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 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 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 24, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that 71045 should be paid as billed because the 
enrollee had multiple exams on the same date of service. The Plan denied your request. The Plan says payment 
for code 71045 is bundled into payment for code 36556. 
 
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 71045 
is a column II code to column I code 36556, which was billed on the same day by a physician of the same 
specialty in the same billing group, which is considered the same provider. 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 71045 billed for date of 
service June 24, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for D0210. We decided that the Plan does not have to pay for D0180.  
 
You asked the Plan to pay for a comprehensive periodontal evaluation (D0180), and intraoral imaging (D0210) 
provided on August 3, 2023. You say that you disagree with these charges. The Plan says that these services 
have been processed and denied correctly. 
 We decided that the Plan has to pay for D0210.  
 
 Evidence was not provided to verify that the dental benefit for D0210 was previously exhausted. Therefore, we 
decided that the Plan has to pay for D0210.  
 
We also decided that the Plan does not have to pay for D0180. 
 
 D0180 is not a covered dental benefit. Therefore, we decided that the Plan does not have to pay for D0180. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker. 
 
You asked the Plan to pre-approve the requested walker. You say that the enrollee needs a walker to ambulate 
around the house. The Plan denied your request. The Plan says the request does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that heavy-duty walkers are only covered under 
certain medical indications.  
 
 We looked at the file and Medicare rules. The requested walker is covered when the enrollee weighs more than 
300 pounds. In this case, the enrollee is not more than 300 pounds. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a heavy-duty walker.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on April 03, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that these services were rendered in good will 
without requesting authorization to avoid delay. 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 skilled nursing facility 
provided on April 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating cold pad with pump (E0218) provided 
April 8, 2023, to April 21, 2023. 
 
You asked the Plan to pay for the water circulating cold pad with pump. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the water circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating cold pad with pump (E0218) provided April 8, 2023, to April 21, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on June 28, 2023. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that the physician did not realize authorization 
was needed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit 
provided on June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hereditary pharmacogenomic testing 
provided on May 18, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is covered for the 
indications established in the applicable NCD. 
 
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 testing. Our reviewer says that the 
requested pharmacogenomics testing was not medically reasonable and necessary. Our physician reviewer 
found that the enrollee has a history of chronic pain and major depressive disorder. There is no documentation 
of the need for a medication with a known gene-drug interaction. The requested testing was not medically 
reasonable and necessary according to the coverage criteria established in the NCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the comprehensive hereditary pharmacogenomic testing provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 14, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 8, 2022, to 
August 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of diagnosis code K85.90. The Plan denied your request. The Plan says the 
medical records do not support the billing of diagnosis code K85.90. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with K85.90. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the medical records do not support the billing of diagnosis code K85.90. Our physician reviewer found the 
enrollee is with systemic lupus, chronic pancreatitis, diabetes mellitus, and bronchiectasis who presented with 
abdominal pain and nausea with hematemesis and dark stools 2-3 weeks prior. Computed tomography (CT) 
showed pseudocyst on pancreas tail fistulized to stomach causing peritoneal abscess. Lipase (3 u/L) was not 
greater than 3x normal but was low. Acute pancreatitis criteria, therefore, were not met for this code, K85.90.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 8, 2022, to August 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable imaging services provided on April 12, 2023. 
 
You asked the Plan to pay for portable imaging services. You say that you are Medicare certified in the state 
where services were provided. 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 portable imaging 
services provided on April 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary for the 
enrollee's memory loss and to determine the type of treatment needed. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not noted to meet 
diagnostic criteria for either AD and FTD. In such a setting the base requirement of the NCD would not be met. 
In as much this request cannot be said to meet the Medicare criteria for coverage. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve procedure (64624). 
 
You asked the Plan to pre-approve a genicular nerve 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 a genicular nerve 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 insufficient literature to support the safety and efficacy, as defined 
by Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve procedure (64624).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99291 billed for date of service December 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for a medically necessary 
procedure. The Plan denied your request. The Plan says that laterality was not indicated for the diagnosis.  
 
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 CPT code 99291 was billed with diagnosis code S06.369A, defined as traumatic hemorrhage of 
cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter. The rules say that 
some diagnosis codes indicate laterality. However, the diagnosis code group for traumatic hemorrhage of the 
cerebrum does not include codes that indicate laterality. Based on this information, we decided that Medicare 
rules for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99291 billed for date of service 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87529, 87798) provided on March 1, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
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. Medicare rules also say that providers must 
report the actual number of units provided for each procedure code. 
 
In this case, the CPT Code Manual definition of code 87529 is "Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique". 
 
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 lab services. Our reviewer says that the use of code 
87529 is not supported, and 18 units of code 87798 are not supported by the records provided. Our reviewer 
found that there is no lab order to support code 87529. For code 87798, 18 units are not supported. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (87529, 87798) provided on March 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has several cardiac issues, requiring a mitral 
valve procedure. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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.