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

We decided that the Plan has 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's significant comorbidities, extended hospital stay, medical complexity and ability to tolerate and benefit from intensive rehabilitation program, would benefit from close daily medical supervision at an Inpatient Rehabilitation Facility. The Plan denied your request. The Plan says the enrollee does not meet the requirements. The Plan says that the 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found The Plan erred in its denial of IRF admission.

Per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall significantly complies with the various documentation requirements for IRF admission (e.g., as best summarized by the OT note from 9/4, the PT note from 9/6, and the note from 9/7/23). Indeed, this beneficiary's condition is in fact complex and fragile, and there is every reason to expect that she will participate in and benefit from services to include at minimum PT, OT, physician oversight of polypharmacy and her various comorbidities, and case manager coordination of any additional services that might be needed to in order to make a sustainable return home as well as avoid further preventable readmissions to the acute hospital.

Therefore, the requested inpatient rehab facility admission is approved. 

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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

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: Favorable

 
We decided that the Plan has to pay for procedure code 86870 billed for date of service May 9, 2023. 
 
You asked the Plan to pay for procedure code 86870. You say that this service was necessary and is not a 
bundled code. The Plan denied your request. The Plan says that this code cannot be paid because it has a status 
indicator of "X" on the physician fee schedule, meaning that it is a statutory exclusion. In addition, this code is 
bundled. 
 
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 code at issue is a laboratory service which is not paid on the 
Physician Fee Schedule. This means that a status indicator of "X" does not mean that this service is not 
covered. In addition, we could not verify any other reason this service could not be paid as there is no bundling 
issue that could be found, and the Plan did not indicate the payment with which this code is bundled. The Plan 
has not substantiated their denial in this case. Therefore, we decided that the Plan has to pay for procedure code 
86870 billed for date of service May 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 leads, per month (A4595) 
billed for date of service November 8, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says supplies for a TENS unit is 
included in the rental allowance.  
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance. 
 
 
 We looked at the file and Medicare rules. The records show you received a TENS unit rental. Medicare rules 
say that during the rental of a TENS unit, supplies for the unit are included in the rental allowance. Based on 
this information, we decided that Medicare rules for coverage of electrical stimulator supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies, 2 leads, per 
month (A4595) billed for date of service November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new scooter. 
 
  You asked the Plan to pre-approve a new scooter. You say that you think it would be best if you had a scooter 
that worked properly. You also say that you have been trying to get your scooter fixed since May, which took a 
month for it to be picked up. The Plan denied your request. The Plan says your power scooter was picked up on 
July 18, 2023, and is currently undergoing repairs. The Plan also says that a loaner scooter has been provided to 
you, and your appeal request for a new scooter has therefore been denied. 
 
The Plan follows Medicare rules. Medicare rules say that replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. The rules also say that during the reasonable useful lifetime, 
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary 
equipment owned by the beneficiary. 
 
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 new scooter. Our reviewer says that 
this request is not medically necessary. Our physician reviewer found the scooter you have is less than 5 years 
old and can be repaired. 
 
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 new scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83520, 87798) provided on April 20, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
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 services. Our reviewer says that the use of codes 83520 
and 87798 is not supported by the records provided. Our reviewer found that the medical record does not 
include the specific procedure codes reported with the "not otherwise specified" procedure codes, and therefore 
these procedures cannot be verified. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (83520, 87798) provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 billed for 
February 6, 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 96365, 96366, 96521, and J1817 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump. The definition of code J1817 is insulin for administration through dme (i.e., insulin pump) per 50 units. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate code for these services. 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 
96365, 96366, 96521, and J1817 billed for February 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on May 2, 2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the provider failed to submit orders for the billed visit and failed to 
support the recertification and care rendered based on the primary diagnosis. 
 
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 home health care have been met. The 
record does not include the physician certification for this home health care. Therefore, we decided that the 
Plan does not have to pay for home health care provided on May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 We find that the documentation submitted does not contain records showing the ordering physicians intent that 
the testing in question be performed. Therefore, we decided that the Plan does not have to pay for the drug 
testing services provided on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 21, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim does not 
meet coding standards. 
 
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 the lab services have been met. The 
submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 01402 and 64447 billed for date of service 
February 15, 2023. 
 You asked the Plan to pay for procedure codes 01402 and 64447. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment 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. 
 
We find that CPT code 01402 is not supported in the medical record. Specifically, the record does not contain 
an anesthesia report. Code 01402 cannot be verified. 
 
In this case, we have confirmed that code 64447 is a column II code to column I code 01402. Code 64447 was 
billed with a modifier; however, the medical records provided are insufficient to show that the service billed 
with a modifier is a distinct procedural service. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 01402 and 64447 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 01402 and 
64447 billed for date of service February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this is a covered test. The Plan denied your 
request. The Plan says there is insufficient information to approve this claim. 
 
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 the laboratory services have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 97530. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the services billed. 
 
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 97530 is: Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
 
  We find that CPT code 97530 is not supported in the medical record. Specifically, the provided record does not 
indicate the duration of the activity indicated by the code at issue. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97530 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97530 billed for date of service May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 23, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 15, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a ventilator is the only therapy that will 
manage the enrollee's symptoms and give her a better quality of life. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and severe 
obesity hypoventilation syndrome (OHS), hence respiratory failure. The enrollee does have documented 
improvement with BIPAP with average volume assured pressure support (AVAPS) therapy in the 
hospital. Hence, a home ventilator is not indicated per documentation at this time, since the enrollee does not 
have BIPAP failure. Therefore, a home ventilator is not indicated and AVAPS can be delivered by BIPAP, as 
in hospital per documentation. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 2, 2022, to 
October 31, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims are paid based on HIPPS 
codes. 
 
We looked at the file and Medicare rules. The file does not support the billed HIPPS code. 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 home health services rendered from October 2, 2022, to 
October 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 20, 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 claim was not billed on the correct type of bill. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. 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 home health services rendered on 
April 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36558 billed for April 3, 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 code 36558 is 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 36558 is insertion of tunneled centrally inserted central 
venous catheter, without subcutaneous port or pump; age 5 years or older. 
 
We find that CPT code 36558 is not supported in the medical record. Specifically, there is no documentation of 
the final position of the tip of the central venous device. 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 code 36558 billed for April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on April 
10, 2023. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we 
decided that Medicare rules for coverage of the FoundationOne CDx testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on April 10, 
2023.