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

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87150, 87481, 
87641, 87653, 87798, and 87801 for date of service July 26, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87150, 87481, 87641, 87653, 87798, 
and 87801. 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 a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
 
 We looked at the file and Medicare rules. We looked at the file and Medicare rules. Review of the file shows 
that the services provided were billed individually. The panel provided should be billed with one procedure 
code for the entire panel. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services billed with codes 87150, 87481, 87641, 87653, 87798, and 87801 have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 87150, 
87481, 87641, 87653, 87798, and 87801 for date of service July 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare 
guidelines for admisison 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 the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation 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, 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 
does not support that they would meet criteria for admission to an IRF.  There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain their 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile radiology services coded as 74240, 74230, 72040, 
70100, 70310, and R0070 billed on date of service April 4, 2023. 
 
You asked the Plan to pay for the mobile radiology services. You say that the mobile radiology services should 
be paid as billed because they are supported in the documentation and were medically necessary. The Plan 
denied your request. The Plan says the mobile radiology services coded as 74240, 74230, 72040, 70100, and 
70310 are denied because they were billed with an inappropriate POS and R0070 is denied because it is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS. Additionally, the rules say that no transportation charge is payable unless the 
portable x-ray equipment used was actually transported to the location where the x-ray was taken. 
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, and 70310 were billed with POS 11, 
indicating an office setting. However, documentation shows these radiology services were performed in a 
mobile setting. Regarding code R0070, records do not contain any documentation of the transportation of 
portable x-ray equipment and personnel to the location where the x-ray services were provided. Based on this 
information, we decided that Medicare rules for coverage of the mobile radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the mobile radiology services coded as 74240, 
74230, 72040, 70100, 70310, and R0070 billed on date of service April 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the LTACH criteria 
for placement, and their current needs cannot be met at a lower level of care. You would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says admission to an LTACH 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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VivAer procedure. 
 
You asked the Plan to pre-approve a VivAer procedure. You say that nasal airway remodeling is covered under 
Original Medicare. The Plan denied your request. The Plan says this device has not been shown to be safe and 
effective for treatment of your condition. 
 
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 VivAer procedure. Our reviewer says 
that the requested VivAer procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has nasal obstruction and congestion. There is 
insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific 
conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the requested VivAer procedure is 
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 a VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VivAer procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy (45385) provided on July 19, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that you cannot afford to pay this bill. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the colonoscopy (45385) provided on July 19, 2023, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. You also say the enrollee cannot be adequately care for in their current condition at a 
skilled nursing facility as they require direct daily physician assessment which cannot be performed remotely.  
The Plan denied your request. The Plan says admission to an LTACH 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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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 IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable and 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 the complexity of the patient's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided in the United Mexican States from 
March 11, 2023, to March 24, 2023. 
 
You asked the Plan to pay for hospital services. You say that you are requesting payment for these bills. The 
Plan denied your request. The Plan says services which do not have proof of payment cannot be reimbursed by 
the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that services outside of the United States and its 
territories are not generally covered. The Plan has a worldwide coverage benefit that goes beyond Medicares 
coverage. For that reason, the Plans rules apply. Your contract with the Plan clearly says that you are 
responsible for payment of services up front, then requesting appropriate reimbursement from the Plan with 
proof of payment. 
 
We looked at the file and Medicare rules. The Plan has reimbursed you for the amounts that you have 
submitted proof of payment for. For additional amounts, you must pay for the services up front and then submit 
proof of payment to the Plan for consideration of reimbursement. Based on this information, we decided that 
the Plans rules for coverage of hospital services have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital services provided in the United Mexican States from March 11, 2023, to March 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation services provided by the same 
physician performing the diagnostic or therapeutic service that the sedation supports (99152). 
 
You asked the Plan to pre-approve moderate sedation services. You say that the request is medically necessary. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is not considered reasonable and 
necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia care (MAC) is 
routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely 
reimbursable. 
 
 
 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 moderate sedation services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation of unique circumstances of medical necessity. The review has determined that monitored 
anesthesia care (MAC) is not medically necessary per the LCD policy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve moderate sedation services provided by the same physician performing the 
diagnostic or therapeutic service that the sedation supports (99152).
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 request is medically necessary. The Plan denied 
your request. The Plan says the requested service 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an annual colonoscopy. 
 You asked the Plan to pre-approve the service. You say that your request for an annual colonoscopy to be 
approved. The Plan denied your request. The Plan says you had a colonoscopy in August of 2023. The Plan 
also says that a colonoscopy every 12 months is not approved. 
 
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 service. Our physician reviewer 
found after the 1-year colonoscopy, the interval to the next colonoscopy should be 3 years (that is, 4 years after 
surgery or perioperative colonoscopy) and then 5 years (that is, 9 years after surgery or perioperative 
colonoscopy). Subsequent colonoscopies should occur at 5-year intervals until the benefit of continued 
surveillance is outweighed by diminishing life expectancy. So, yearly colonoscopy is not medically 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an annual colonoscopy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81003 billed for date of service June 10, 
2023. 
 You asked the Plan to pay for procedure code 81003. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 81003 is bundled into payment for 
code 80307. 
 
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 81003 
is a column II code to column I code 80307. 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 81003 billed for date of service June 10, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0425, A0429) provided on April 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the allowable units 
have been exceeded and the ambulance base rate was denied. 
 
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 the allowable units for code A0425 has been exceeded. 
However, the claim was only billed with one unit of code A0425 which is payable. Additionally, the Plan 
argues that code A0429 is not payable as the ambulance base rate was denied. However, as the Plan's denial for 
code A0425 is not substantiated, the denial for code A0429 is also not substantiated. The Plan has not provided 
documentation supporting its denial of the ambulance services. Therefore, we decided that the Plan has to pay 
for the ambulance services (A0425, A0429) provided on April 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 drug testing (G0483) billed for date of service April 20, 
2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says the provided documentation is not sufficient to support the services 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. A 
physician order for the services at issue has not been provided for review. Therefore, we decided that the Plan 
does not have to pay for drug testing (G0483) billed for date of service April 20, 2023.