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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are physically and medically necessary 
for the enrollee. You would like reconsideration based on the records submitted. The Plan denied your request. 
The Plan says admission to an IRF is not medically necessary.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring active compression system (K1033, 
K1024). 
 
You asked the Plan to pre-approve the Koya Dayspring active compression system . You say that the Koya 
Dayspring Active Compression System has been proven effective for the enrollee's ongoing management of 
their lymphedema. The Plan denied your request. The Plan says this device is experimental and investigational 
as 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. There is insufficient evidence in the medical literature to support that 
the requested Dayspring device is as effective as a pneumatic sequential compression device. Additionally, the 
device has Bluetooth technology and a companion application that exceeds medical need. Based on this 
information, we decided that Medicare rules for coverage of the Koya Dayspring active compression system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Koya Dayspring 
active compression system (K1033, K1024).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code U0005 billed for date of service March 3, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the primary 
service code is denied in the system. 
 
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 U0005 is infectious agent detection by nucleic acid; 
severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [Covid-19]), amplified 
probe technique, making use of high throughput technologies, completed within 2 calendar days from date of 
specimen collection (list separately in addition to either code U0003 or U0004). 
 
We find that CPT code U0005 is supported. In this case, we have confirmed that code U0005 is an add-on code 
that has been billed with an appropriate primary procedure code. The file shows that primary code U0003 was 
paid by the Plan on April 11, 2023. 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 U0005 
billed for date of service March 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service April 20, 
2023.   
You asked the Plan to pay for procedure code 20610. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 20610 is 2. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 20610 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 20610 billed for date of service April 20, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services billed with codes 81162, 81201, 81292, 81295, 
81298, 81307, 81317, 81321, and 81351 for date of service December 27, 2022. 
 
You asked the Plan to pay for the laboratory services billed with codes 81162, 81201, 81292, 81295, 81298, 
81307, 81317, 81321, and 81351. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says that the services were not submitted with the required DEX-Z code. 
 
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. No Medicare rule was provided by the Plan that states that these codes require a 
DEX-Z code. Upon further review, no Local Coverage Determination (LCD) or Local Coverage Article (LCA) 
was found to support that these services require the DEX-Z code. No other denial rationale was provided by the 
Plan. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
laboratory services billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, and 81351 for 
date of service December 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic gastric fundoplication. 
 
You asked the Plan to pre-approve a laparoscopic gastric fundoplication. You say that the records provided 
support the need for the service which remains in dispute. The Plan denied your request. The Plan says a 
review of the medical literature indicates that power of hydrogen (pH) monitoring 6-months following a per-
oral endoscopic myotomy (POEM) procedure is appropriate to evaluate for asymptomatic reflux. The enrollee 
has been separately approved for the esophagogastroduodenoscopy. The Plan says that the requested service is 
not medically necessary. 
 
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 laparoscopic gastric fundoplication. 
Our reviewer says that a laparoscopic gastric fundoplication is not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation demonstrating why a 
laparoscopic gastric fundoplication is necessary. The notes show that the enrollee was doing well after the 
POEM. There was no data shared showing that the pH study demonstrated significant reflux after POEM. 
 
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 laparoscopic gastric fundoplication have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a laparoscopic gastric fundoplication.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 29, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from August 29, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
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 pre-approve inpatient psychiatric care from August 
29, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of August 29, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond August 29, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
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 care from August 29, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 29, 
2023, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) testing rendered 
on March 22, 2023. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that PCR testing must be billed as one unit of service. 
 
We looked at the file and Medicare rules. The file shows that the testing was not billed as one unit of service. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) 
testing rendered on March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86256 billed for date of service February 16, 
2023. 
 
You asked the Plan to pay for procedure code 86256. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while outpatient. In this case, an appropriate 
modifier to indicate the professional/technical component has not been billed with CPT code 86256. Based on 
this information, we decided that Medicare rules for coverage of procedure code 86256 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 86256 billed for date of service 
February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes (G0483).

You asked the Plan to pay for definitive UDT for 22 or more drug classes. You say that this drug screening provides valuable information for physicians to use in determining the appropriate medication at the appropriate dosage. The Plan denied your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee.

The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the rules section of this letter are met.

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 definitive UDT for 22 or more drug classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the member. Under Medicare rules, the number of definitive urine drug classes requested 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 definitive UDT for 22 or more drug classes have not been met. Therefore, we decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes (G0483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on April 5, 2023. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code 
which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87481, 87653, and 87798 billed for 
December 14, 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 the services are not covered. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records do not identify 
the multiple organisms tested. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. 
 
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 codes 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and distinct procedural 
service. 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 codes 87801, 87481, 87653, and 87798 
billed for December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36556 and 76937 billed for April 13, 2023. 
 
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 codes 36556 and 76937 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. The definition of code 76937 is ultrasound guidance for vascular 
access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, 
concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting 
(List separately in addition to code for primary procedure). 
 
We find that CPT codes 36556 and 76937 are not supported in the medical record. Specifically, there is no 
documentation of the final position of the tip of the central venous device to support code 36556. There is no 
documentation of the selected vessel patency and documentation of permanently recorded images to support 
code 76937. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 36556 and 76937 billed 
for April 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that continuation of Skilled Nursing Facility services for 
the enrollee is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that a Cala Trio device is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says a Cala Trio device is 
experimental/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 pre-approve a Cala Trio device. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records in this case do not document trial and failure of all standard 
pharmacologic treatments for essential tremor. The records do not clarify that the Cala Trio device is safe and 
effective, not experimental or investigational, is furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body 
member. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018).