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

 
We decided that the Plan does not have to pay for code 73630 billed for date of service December 28, 2022. 
 
You asked the Plan to pay for code 73630. You say that code 73630 was medically necessary and should be 
paid. The Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim 
includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- packaged 
service, the payment for the STV-packaged service is packaged into the payment for the service(s) with status 
indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged services are 
assigned status indicator Q1.   
In this case, code 73630 has a status indicator of Q1, meaning that it is a STV-packaged service.  It was billed 
on the same claim as code 99283, which has a status indicator of V.  This means that code 73630 is not 
separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 73630 have not been met. Therefore, we decided that the Plan does not have to pay for code 
73630 billed for date of service December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 28, 2022. 
 
You asked the Plan to pay for lab services. You say that this should be covered. The Plan denied your request. 
The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require or waive prior authorization rules for obtaining POS services. The Plan contract says that lab services require 
prior authorization. 
 
We looked at the file and Medicare rules. The lab services at issue were not authorized. Based on this 
information, we decided that Medicare rules for coverage of lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services provided on December 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twice daily skilled nursing visits (38 additional skilled 
nursing visits). 
 You asked the Plan to pre-approve home health services. You say that the enrollee's family does not participate 
in care during either of twice daily nursing visits are uninterested in medication administration teaching. The 
requested services are not medically necessary or reasonable. The Plan denied your request. The Plan says 
there is no evidence to support twice daily nursing visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee is not homebound, and twice daily visits would not be considered to be intermittent.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twice daily skilled nursing visits (38 additional skilled nursing visits).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on February 23, 2022, billed with 
code 95822-26-XU. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 95822-26-XU is Electroencephalogram (EEG); recording 
in coma or sleep only. 
 
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 testing services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found the medical records provided does not 
include sufficient documentation to validate that an electroencephalogram (EEG); recording in coma or sleep 
only was performed on February 23, 2022, therefore this procedure 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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on February 23, 2022, billed with code 95822-26-XU.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 14, 2022, to 
October 13, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support the necessity of these services. 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 September 14, 2022. The NOA was not received by the Plan until 
November 4, 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 September 14, 2022, to October 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from August 4, 2022, to 
August 8, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
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 DRG 872. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the records do not show that the enrollee had sepsis. The Sequential Organ Failure Assessment (SOFA) 
score was zero.  
 
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 rendered from August 4, 2022, to August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation of a diagnosis of 
bronchiectasis, cystic fibrosis, or neuromuscular disease. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the ostomy pouch, drainable; for use on barrier with non-
locking flange, with filter (2-piece system), each (A4425) provided January 17, 2023.  
 
You asked the Plan to pay for  the ostomy supplies. You say that you would like to appeal the denial of the 
claim because you do not get 80 units per month, it is every 3 months. The Plan denied your request. The Plan 
says this service exceeds the maximum quantity allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Per Local Coverage Determination (LCD) Ostomy Supplies L33828, 
the maximum quantity listed for A4425 is 20 units per month. In this case the provider as billed for 80 units 
which exceeds the maximum quantity allowed. Based on this information, we decided that Medicare rules for 
coverage of the ostomy supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for  the ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2-piece system), each 
(A4425) provided January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F2 (Prothrombin, Coagulation Factor II) (E.g., 
Hereditary Hypercoagulability) Gene Analysis, 20210G>A Variant x 1 (81240). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says  the genetic test (Factor II Prothrombin Genotyping) is not reasonable or 
necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that this is a non-coverage policy for genetic testing for 
thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) 
variant in the F2 gene, and the MTHFR gene which encodes the 5,10-methylenetetrahydrofolate reductase 
enzyme. Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including 
cardiovascular risk assessment, are non-covered except for pregnant patients. Therefore, this test is not 
covered. We looked at 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 pre-
approve the F2 (Prothrombin, Coagulation Factor II) (E.g., Hereditary Hypercoagulability) Gene Analysis, 
20210G>A Variant x 1 (81240).
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 stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 enrollee does require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a 
week, or 15 hours over seven consecutive days. As of May 24, 2023, the enrollee was dressing and grooming 
with stand by assistance. The enrollee was completing transfers with stand by assistance but fatigued quickly. 
The enrollee was requesting to ambulate. The enrollee performed sit to stand transfers from a recliner with 
minimal assistance. The enrollee was able to stand but their oxygen levels desaturated. The enrollee has had a 
decline from their baseline level of function and would benefit from occupational and physical therapies. The 
enrollee requires closer medical and therapy oversight given the enrollee's oxygen status and oxygen 
desaturation with activity. Therefore, the acute inpatient rehabilitation admission is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 20, 2022 to 
April 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the Plan should review this 
claim. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 20, 2022 to April 
18, 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 the enrollee requires inpatient rehabilitation level of 
care. The Plan denied your request. The Plan says the enrollee does not meet the requirements. 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
(3) visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services 
at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
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. 
 
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 a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the diagnosis of COPD is not confirmed by spirometry. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service December 9, 2022. 
 
You asked the Plan to pay for code 99233. You say that the diagnosis codes billed are payable. The Plan denied 
your request. The Plan says you billed two diagnoses that cannot be billed together. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used 
when two conditions cannot occur together, such as a congenital form versus an acquired form of the same 
condition. 
 
In this case, you billed the claim for the services in dispute with diagnosis codes J44.1 and J47.9.  However, 
diagnosis code J47.9 is listed as an Excludes1 code to code J44.1.  This means that these two diagnoses cannot 
be billed together. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99233 billed for date of service December 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes 33207 and 99153 billed for date of service August 30, 2022. 
 
You asked the Plan to pay for codes 33207 and 99153. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says that for code 33207, the service does not meet 
the coverage criteria of the Local Coverage Determination.  For code 99153, this service was not billed 
appropriately. 
 
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 has provided little to no explanation of its denial rationale.  
In its Remittance advice, the Plan stated that the service does not meet criteria.  However, the Plan has made 
absolutely no effort to explain what criteria, if any, are not met. Further, the Plan has failed to cite to any 
specific coverage rule upon which this denial is based.  The burden is on the Plan to show why its denial is 
correct.  By failing to provide even a minimal amount of analysis to support its denial, we find that the Plan has 
not met this burden. Therefore, we decided that the Plan has to pay for codes 33207 and 99153 billed for date 
of service August 30, 2022.  
 
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 you are requesting an expedited reconsideration 
for the denial of an IRF admission. You say the enrollee continues to have decreased strength, decreased 
endurance and gait deficits which are improving as the enrollee is eager to work with physical and occupational 
therapy. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.