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

 
We decided that the Plan does not have to pre-approve a repeat sleep study (95811). 
 
You asked the Plan to pre-approve a repeat sleep study. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that a single polysomnography (PSG) is usually sufficient 
to titrate pulmonary artery pressure (PAP) therapy. 
 
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 repeat sleep study. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee does not meet criteria 
for repeat sleep study per documentation provided. 
 
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 repeat sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat sleep study (95811).
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 these services are medically necessary. The Plan 
denied your request. The Plan says the enrollee can receive services at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on May 24, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that the provider is in network and the 
enrollee has had multiple paid claims. You say that the patient also has Medicare as primary, but the provider is 
not enrolled with Medicare.  The Plan denied your request. The Plan says the guidelines for coverage have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on May 
24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the plan approved the inpatient admission and lumbar fusion. However, there is no 
specific indication provided to support the request for bone marrow aspirate for the approved surgery.  
 There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow 
aspirate for this enrollees medical condition as discussed above. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested bone marrow aspiration 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration for bone grafting (20939).
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 needs to be transferred to the 
LTACH to regain maximum/prior level of functioning and to continue a multi-disciplinary approach to care. 
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 the enrollee is receiving the appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at 
this time. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service April 10, 
2023.  
You asked the Plan to pay for procedure code 76942. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 76942. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 76942. Based on this information, 
we decided that Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76942 billed for date of service April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 29, 2023. 
 
You asked the Plan to pay for OIVIT services. 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. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital inpatient or observation care (99233) provided from 
January 19, 2023, to January 25, 2023. 
 
You asked the Plan to pay for the hospital evaluation. You say that the records submitted support code 99233 
and should be paid. The Plan denied your request. The Plan says that the medical records provided do not 
support the high level of medical decision making or the total time required of the code 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 99233 is the subsequent hospital inpatient or observation 
care which requires a medically appropriate history and/or examination and high level of medical decision 
making. 
 We asked our physician 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 hospital evaluation. Our reviewer found that the 
medical records submitted did not document the time or the degree of medical decision making to support code 
99233 billed on the dates of service provided.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the hospital evaluation have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital inpatient or observation care (99233) provided from January 19, 2023, to 
January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 for date of service June 12, 2023. 
 
You asked the Plan to pay for procedure code 87506. 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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
 
 We find that CPT code 87506 is not supported in the medical record. Specifically, the medical records indicate 
that more than 11 targets were performed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87506 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87506 for date of service June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed for date of service July 12, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says there are inconsistencies in the medical 
record which mean the services at issue cannot be verified as reported. 
 
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 laboratory services have been met. 
Specifically, there are inconsistencies in the records regarding the date of specimen collection for these tests. 
We cannot verify whether the services at issue were reported in accordance with Medicare guidelines. 
Therefore, we decided that the Plan does not have to pay for laboratory services billed for date of service July 
12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics billed with codes A5500 and A5513 for date of 
service March 8, 2023. 
 
You asked the Plan to pay for orthotics. 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 when codes are billed without a KX modifier, 
they will be denied as noncovered. 
 
We looked at the file and Medicare rules. Review of the file shows that codes A5500 and A5513 were billed 
without the KX modifier. Based on this information, we decided that Medicare rules for coverage of orthotics 
have not been met. Therefore, we decided that the Plan does not have to pay for orthotics billed with codes 
A5500 and A5513 for date of service March 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 18, 2022, to 
September 16, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim has been under review since 
December of 2022. 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 May 20, 2022. The NOA was not received by the Plan until October 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 18, 2022, to September 16, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that given the enrollee is high risk and has already failed 
bisphosphonate therapy, you recommend they receive Prolia therapy. The Plan denied your request. The Plan 
says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
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 services are medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 16, 2023, billed 
with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel 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 
February 16, 2023, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798 
and U0005.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 84443) rendered on June 
14, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 84443 remains 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 84443 is "Thyroid stimulating hormone (TSH)." 
 
We find that CPT code 84443 is not supported in the medical record. Specifically, the records do not contain an 
order or requisition for these services. 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 laboratory 
services (procedure code 84443) rendered on June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81345) provided on May 16, 2023. 
 
You asked the Plan to pay for the lab services. You say that the services at issue were a medical necessity for 
the enrollee. 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 (81345) provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service April 26, 
2023. 
 
You asked the Plan to pay for the billed 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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the 
medical record. Train of four monitoring is considered integral to intraoperative monitoring and/or 
administration of anesthesia. There is no separate code for Train of Four Monitoring. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95937 billed for date of service April 26, 2023.