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 needs the attention needed to regain 
strength, stamina, ability to walk, readmission to health to help ensure long term recovery and not just a short-
term fix at a lesser institution. The Plan denied your request. The Plan says this 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 On review of the available records, the enrollee with history of debility from acute 
illness as described above does not meet CMS coverage criteria for IRF admission. 
The enrollee is medically stable and does not need PMR physician's supervision 3 times a week in an IRF. 
 No acute rehab nursing needs identified or documented. 
 At the current high functional level, the enrollee does not need intensive therapies consisting of at least 3 hours 
of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
Document does not support necessity for admission to an IRF. The complexity of the enrollee's medical, rehab, 
and nursing needs (combined complexity) does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. 
The enrollee's rehab needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from August 10, 2022, to 
September 8, 2022. 
 
You asked the Plan to pay for home health care. You say that the Plan has not provided any means of 
submitting a Notice of Admission (NOA). The Plan denied your request. The Plan says the required Notice of 
Admission (NOA) has not been submitted to the Plan. 
 
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. 
Specifically, no Notice of Admission (NOA) has been submitted to the Plan. Medicare requires the NOA for 
processing of home health claims as of January 1, 2022. Therefore, we decided that the Plan does not have to 
pay for home health care provided from August 10, 2022, to September 8, 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 inpatient rehabilitation is medically necessary. The 
Plan denied your request. The Plan says inpatient rehabilitation 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 does 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. There is 
not a reasonable expectation that this 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93306) provided on December 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography". 
 
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 code 93306 is 
not supported by the records provided. Our reviewer found that the procedure report describes an examination that does not evaluate or document the attempt to evaluate all the structures that are required for a complete 
echocardiographic exam. In this case, the documentation does not include sufficient documentation to support 
the billed code. 
 
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 (93306) provided on December 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service October 15, 
2022, to November 13, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 October 15, 2022. The NOA was not received by the Plan. 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 the home health services for date of service 
October 15, 2022, to November 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes J2260, A4222, and A4221 for date of service August 
12, 2022, to August 19, 2022. 
 You asked the Plan to pay for codes J2260, A4222, and A4221. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The documentation submitted did not include an injection of milrinone lactate, 5 mg note for the billed date of 
service; therefore, code J2260 cannot be verified. The record does not contain a valid physician order and proof 
of delivery for the supplies provided in this case. This means the supplies identified with codes A4222 and 
A4221 are not supported. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for codes J2260, 
A4222, and A4221 for date of service August 12, 2022, to August 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 97110, 97116, and 97530 for date of service October 
20, 2022. 
 
You asked the Plan to pay for codes 97110, 97116, and 97530. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
The CPT Code Manual definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 minutes; 
gait training (includes stair climbing). 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 97110, 97116, and 97530 is not supported in the medical record. Specifically, the 
documentation submitted does not indicate that a minimum of 8 minutes was spent providing this therapy 
service on this date of service; therefore, code 97110 cannot be verified. The documentation submitted does not 
indicate that a minimum of 8 minutes was spent providing this therapy service on this date of service; therefore, 
code 97116 cannot be verified. The documentation submitted does not indicate that a minimum of 8 minutes 
was spent providing this therapy service on this date of service; therefore, code 97530 cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of codes 97110, 97116, and 97530 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 97110, 97116, and 
97530 for date of service October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided on March 6, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99239 is hospital discharge day management of more 
than 30 minutes.  
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show how 
much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99239) provided on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on April 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service July 5, 2022. 
 You asked the Plan to pay for procedure code 88305. You say that the services were provided in good faith. 
The Plan denied your request. The Plan says payment for code 88305 is bundled into payment for code 88321. 
 
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 88305 is a column II code to column I code 88321. Code 88305 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 88305 
billed for date of service July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because based on the medical literature this 
procedure is considered experimental or investigational and has not been proven to be beneficial for 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental/ investigational. It is the subject of ongoing 
clinical trials.  
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64624).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0318 billed for date of service May 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that bundling the code conflicts with reimbursement 
policies. The Plan denied your request. The Plan says that procedure code 99350 is included in procedure code 
G0318. 
 
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 G0318 is Prolonged home or residence evaluation and 
management service(s) beyond the total time for the primary service (when the primary service has been 
selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified 
healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 
99350 for home or residence evaluation and management services). 
 
We find that CPT code G0318 is supported. In this case, we have confirmed that code G0318 is an add-on code 
that has been billed with appropriate primary procedure code 99350, which has been paid by the Plan. Based on 
this information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, 
we decided that the Plan has to pay for procedure code G0318 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test billed for date of service 
December 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the test is a Medicare covered benefit. The Plan 
denied your request. The Plan says the unique identifier was not billed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 81529-59 was billed. We looked at the file and Medicare rules. Review of the 
claim at issue does not show that the required unique identifier was reported. 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 the DecisionDx-Melanoma test billed for date of service December 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 7, 2022, to 
October 11, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says A41.9 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that diagnosis code A41.9 is not sufficiently supported 
in this documentation. Our physician reviewer found the enrollee has a history of dementia and presented to the 
emergency department with pneumonia. They were initially noted to be alert and oriented to self and place. 
Workup revealed creatinine was 1.5 (enrollee's baseline), normal bilirubin, normal platelets, hypoxia (oxygen 
saturation 86%), and no growth on blood culture. The enrollee was started on intravenous (IV) fluids, 
antibiotics, bilevel positive airway pressure (BiPAP), oxygen support, and bronchodilators. The patient did not 
have oliguria but did have mean arterial pressure (MAP) of 68-69. The enrollee had pneumonia, so the hypoxia 
was not unexpected for this diagnosis. They had dementia with neurological status unchanged comparing 
admission to discharge status. They had no measurable elevation in creatinine, but did have low blood pressure, 
assigning a Sequential Organ Failure Assessment (SOFA) score of 1, when 2 or more would be needed to meet 
Sepsis 3 criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 7, 2022, to October 11, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services coded as 99222 
performed on March 12, 2023. 
 
You asked the Plan to pay for 99222. You say that 99222 billed on March 12, 2023, should be covered because 
it is supported in the documentation. The Plan denied your request. The Plan says 99222 is denied because it is 
not supported in the documentation. 
 
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 99222 is initial 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 moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 minutes must be met or exceeded.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 99222. Our reviewer says that 99222 is not 
supported in the record. Our reviewer found documentation supports an appropriate exam, but not an 
appropriate history or medical decision making of moderate level. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99222 have not been met. Therefore, we decided that the Plan does not have to 
pay for evaluation and management services coded as 99222 performed on March 12, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a leadless pacemaker (33274). 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that this is medically necessary. The Plan 
denied your request. The Plan says that there is no documentation supporting the enrollee is participating in an 
approved study. 
 
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 Plans rationale is not valid because the leadless pacemaker has a clinical 
registry which tracks claims data after the pacemaker insertion. As such, there is no participation in a clinical 
trial until after the pacemaker has been placed. Therefore, we decided that the Plan has to pre-approve a 
leadless pacemaker (33274).  
 
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.