Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 93010 and 99291. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 99053.  
 
You asked the Plan to pay for procedure codes 93010, 99291, and 99053 billed for date of service June 15, 
2022. You say that 93010, 99291, and 99053 should be paid as billed because they are supported in the 
documentation. The Plan says that 93010 and 99291 are being handled as an original decision reopen for New 
and Material Evidence, therefore no coverage decision was made. 99053 is denied because it is considered 
bundled and not separately payable.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 93010 and 99291.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 93010 and 99291.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99053. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate procedure code. The rules also say that no separate payment is made 
for codes with a Status Indicator of B on the Physician Fee Schedule.  
 
We looked at the file and Medicare rules. We find that procedure code 99053 has a status indicator of B on the 
Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 99053 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 99053. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74018, 99283 and Q9963 rendered on April 
24, 2023. You asked the Plan to pay for the procedure codes 74018, 99283 and Q9963. You say that the services were 
medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure codes 74018, 99283 and Q9963 rendered on April 
24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 8, 2023, billed with 
codes 87150, 87798, and 87481. 
 
You asked the Plan to pay for the genetic testing billed. You say that the lab results show that all work was 
performed. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on August 8, 2023, billed with codes 87150, 87798, and 87481.
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 are requesting reconsideration of the denied IRF 
admission. The Plan denied your request. The Plan says IRF care 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 patient has modest functional loss and is deconditioned. The patient is 
transferring and walking at a home care level of function. The patient does not require intensive rehabilitation 
services.  
 
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 pay for the subsequent hospital inpatient care (99233) and corpora 
cavernosa-saphenous vein shunt (priapism operation) (54420) provided on January 11, 2023. 
 
You asked the Plan to pay for the inpatient hospital care and priapism operation. You say that these services 
should be paid. The Plan denied your request. The Plan says the services at issue were not billed correctly. 
 
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 54420 is corpora cavernosa-saphenous vein shunt 
(priapism operation), unilateral or bilateral. The CPT Code Manual definition of code 99233 is subsequent 
hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires 
a medically appropriate history and/or examination and high level of medical decision making. When using 
total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.  
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 inpatient hospital care and priapism operation. Our 
reviewer found that the procedure report does not include documentation of corpora cavernosa-saphenous vein 
shunt (priapism operation), unilateral or bilateral. The documentation also does not show that a high level of 
decision making was provided. Therefore, codes 54420, 99233 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 inpatient hospital care and priapism operation have not been met. Therefore, 
we decided that the Plan does not have to pay for the Subsequent hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 50 minutes must be met or exceeded (99233) and corpora cavernosa-saphenous vein shunt 
(priapism operation), unilateral or bilateral (54420) provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain/ceramic (D2740), retainer crown 
(D6740), pontic (D6245), surgical placement of implant body (D6010), custom fabricated abutment (D6057), 
surgical access to an implant body (D6011) and abutment supported crown (D6058). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown-porcelain/ceramic (D2740), retainer crown (D6740), pontic (D6245), surgical placement of implant 
body (D6010), custom fabricated abutment (D6057), surgical access to an implant body (D6011) and abutment supported crown (D6058).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you were told these services were covered, 
and you cannot afford to pay for them. 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 April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 80 additional one-way trips. 
 
You asked the Plan to pre-approve 80 additional one-way trips. You say that you are appealing. The Plan 
denied your request. The Plan says your benefit only allows 72 trips for this service. The Plan also says that 
you have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 80 additional one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 billed for date of service July 3, 2023. 
 
You asked the Plan to pay for the billed service. You say that the enrollee was seen for a medically necessary 
procedure. The Plan denied your request. The Plan says the code is not payable with the billed place of service. 
 
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 code 69209 was billed with a place of service code 23, a 
hospital emergency room. Code 69209 has a PC/TC indicator of 5. Payment may not be made for these 
services when they are provided to those in a hospital outpatient department. Based on this information, we 
decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 69209 billed for date of service July 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1852), provided on June 29, 2023. 
 You asked the Plan to pay for the knee orthosis. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee had a recent injury to or surgery 
on the knee, or that they have an unstable knee on exam. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for L1832, L1833, L1843, L1845, L1850, 
L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria 
for coverage. For example, they will be denied if only pain or a subjective description of joint instability is 
documented. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee orthosis have not been met. Therefore, we decided that the Plan does not have to pay for 
the knee orthosis (L1852), provided on June 29, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you live alone, bath and facilities are on the 2nd 
floor, and you are unable to walk, currently working with physical therapy. The Plan denied your request. The 
Plan says that you are medically stable and no longer require daily skilled therapy to be delivered by a licensed 
therapist. The Plan also says skilled therapy needs could now safely be met on an intermittent basis. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that your past level of function was modified 
independent with mobility and self-care tasks and requiring moderate assistance with transfers, max assist with 
bathing/toileting thus significantly beneath functional baseline with mobility and self-care tasks. 
Interdisciplinary team document states that you are participating with skilled therapy and the plan is to 
discharge to your home and evaluating therapy notes show progress with transfers and bed mobility. Evaluating 
therapists document continued discharge medical equipment evaluation thus daily inpatient skilled therapy 
goals are specified. There have been multiple medical and functional complications during your SNF stay 
currently. Skilled nursing notes document close blood pressure and pain management assessment due to 
intractable hip pain thus frequent skilled nursing assessments and daily skilled services are warranted. From a 
practical standpoint, clinical documentation supports the medical necessity of continued daily skilled services 
on an inpatient basis in a skilled nursing facility. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can't go home without having these 
services. The Plan denied your request. The Plan says these services can be provided in an alternate setting.  
 
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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies. 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hereditary hemochrosis gene analysis (81256).

You asked the Plan to pre-approve the genetic testing. You say that you are appealing the denied genetic testing. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested genetic testing. This test is not indicated at this time.
 
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 the genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's transferrin saturation needs to be greater than 45%. Although the enrollees was 75%, this is in the setting of taking iron supplements which could give a false elevation. Therefore, the medical records do not show that the requested testing meets the requirements listed in the LCD for Medicare 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve hereditary hemochrosis gene analysis (81256).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and
electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that
you disagree with the denial. The Plan denied your request. The Plan says that these items are not medically
necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness and electronic connection. Our Medical Director states that the enrollee has multiple
sclerosis. A mobility evaluation dated March 15, 2023, indicated that the patient has bilateral 3-/5 finger
intrinsic strength, bilateral 2/5 wrist flexion and extension motor strength, bilateral 3/5 elbow flexion and
extension motor strength, and 2/5 shoulder flexion and abduction strength. He is dependent for transfers and
has a history of pressure wounds. The available documentation does not support that it is medically necessary
for the enrollee in this case to control the power options through a joystick. Our Medical Director found that
the enrollee's condition does not meet criteria for coverage of an expandable controller, harness and electronic
connection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller, harness and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness
(E2313) and electronic connection (E2311) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that continued SNF care is necessary. The Plan denied 
your request. The Plan says the enrollees 100 day benefit for SNF care has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 22, 2023, to 
November 26, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve SNF care.