Persius/hicric huggingface dataset:
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 meets all the criteria to go to IRF and 
potential to make excellent progress. The Plan denied your request. The Plan says the enrollee's records do not 
show that you need an intensive team for your care. Services needed may be provided safely in a lower level of 
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 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee does meet Medicare criteria for acute 
inpatient rehabilitation. You say that the rehabilitation the enrollee needs cannot be accomplished at a lower 
level of care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 
30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was coded correctly. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient. We find that CPT code 99285 was billed with place of service code 22, an 
outpatient hospital facility. There is a more appropriate place of service code that identifies services provided in 
an emergency department. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 
billed for date of service November 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 18, 2022, to 
June 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that your company had a software 
issue that prevented you from filing NOA claims. The issue has now been fixed, but the claim is still denying. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 18, 2022, to June 
12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthrotomy with synovectomy (27335) provided on 
January 23, 2023. 
 
You asked the Plan to pay for the knee arthrotomy with synovectomy (27335). You say that the claim should 
be processed for payment. The Plan denied your request. The Plan says procedure code 27335 is considered 
inclusive to procedure 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; however, 27335 
was billed with a modifier.  
 
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 knee arthrotomy with synovectomy (27335). Our 
reviewer says that modifier 59 is not supported. Our reviewer found the operative report describes a 
synovectomy and total knee arthroplasty performed on the same knee. Since both procedures were performed 
at the same anatomical area, this procedure denied correctly as bundled. 
 
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 knee arthrotomy with synovectomy (27335) have not been met. Therefore, 
we decided that the Plan does not have to pay for the knee arthrotomy with synovectomy (27335) provided on 
January 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four monitoring billed for date of service June 1, 
2022. 
 You asked the Plan to pay for the billed services. You say that train of four is integral as the benchmark. The 
Plan denied your request. The Plan says the service is not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that train of four services are an integral part of the intraoperative 
neuromonitoring and not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
train of four monitoring billed for date of service June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99348) provided on January 12, 2023. 
 
You asked the Plan to pay for the home visit (99348). You say that the service should be covered. 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 home visit (99348) 
provided on January 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 31, 2022, to 
September 23, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial and request 
reconsideration. 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 August 31, 2022. The NOA was not received by the Plan until March 7, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 31, 2022, to September 23, 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 your progress has declined due to your inability to 
receive physical and occupational therapy services. The Plan denied your request. The Plan says you do not 
meet the criteria for admission to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is needing the additional services to 
regain maximum functioning. The Plan denied your request. The Plan says the enrollee's condition does not 
meet the requirements. Services needed may be provided safely in a lower level of 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 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. 
 
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 00790 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says there is a more appropriate code that should be used. 
 
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 00790 is anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; not otherwise specified. We find that CPT code 00790 is not supported 
in the medical record. The file shows a right hemicolectomy procedure was provided. There is a more accurate 
code available to describe anesthesia for intraperitoneal procedures in the lower abdomen. Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 00790 billed for date of 
service July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
October 12, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care (99309). You say that the service should be 
covered. 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 subsequent nursing 
facility care (99309) provided on October 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 31, 2022, to 
September 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA is on file with 
the Plan. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 31, 2022, to 
September 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99350 for date of service March 29, 2023. 
 
You asked the Plan to pay for procedure code 99350. 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Review of the file shows that code 99350 was billed with diagnosis 
codes E08.29 (Diabetes mellitus due to underlying condition with other diabetic kidney complication) 
and E11.65 (Type 2 diabetes mellitus with hyperglycemia). Due to an Excludes 1 note, these two diagnosis 
codes should not be reported together. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99350 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99350 for date of service March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 29, 2022, to 
December 6, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial and request a 
review and reprocess of the claim. 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 November 29, 2022. The NOA was not received by the Plan until February 
7, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 29, 2022, to December 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services, X-Ray, and physician visit provided 
from December 1, 2022, to December 6, 2022.  
You asked the Plan to pay for home infusion services. You say that the idea that the Plan would only reimburse 
this amount is incomprehensible. The Plan denied your request. The Plan says the Plan has paid more than the 
Medicare allowable amount for these services, so additional payment is not warranted. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee. Medicare rules say that the allowable amount of physician/professional services is set by the Medicare 
Physician Fee Schedule. The allowable amount of the services billed is shown in the following table: 
 
Date of Service Service Provided 
Billed 
Amount 
Allowed 
Amount 
Amount Paid 
by the Plan 
December 1, 2022 Home Visit 99348 $225 $96.63 $98.08 
December 1, 2022 Infusion 96360 $650 $42.73 $42.73 
December 1, 2022 Infusion 96374 $350 $49.02 $157.50 
December 1, 2022 X-Ray 71045 (99199) $350 $32.51 $350 
December 2, 2022 Infusion 96374 $850 $49.02 $49.75 
December 3, 2022 Infusion 96374 $850 $49.02 $49.75 
December 4, 2022 Infusion 96374 $850 $49.02 $49.75 
December 5, 2022 Infusion 96374 $850 $49.02 $49.75 
December 5, 2022 Infusion 96374 $850 $49.02 $49.75 
December 6, 2022 Infusion 96375 $225 $19.79 $20.09 
December 6, 2022 Infusion 96374 $850 $49.02 $49.75 
Total  $6,900 $534.80 $966.90 
 
Therefore, the Plans reimbursement amount of $966.90 is more than the total Medicare allowable amount for 
these services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home infusion services have not been met. Specifically, the record indicates that the Plan has paid 
more than the Medicare allowed amount for these services. A Medicare provider should accept the Medicare 
allowed amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains 
after the Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for home 
infusion services, X-Ray, and physician visit provided from December 1, 2022, to December 6, 2022.
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 needs a high level of care 
and cannot return home. The Plan denied your request. The Plan says the enrollee's records do not show that 
your continued treatments and care can only be given in a hospital setting. When ready to leave the hospital, 
services needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services during procedure identified with 
code 54520 for date of service December 21, 2022. 
 
You asked the Plan to pay for assistant surgeon services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 54520. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
assistant surgeon services have not been met. Therefore, we decided that the Plan does not have to pay for 
assistant surgeon services during procedure identified with code 54520 for date of service December 21, 2022.