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

 
We decided that the Plan does not have to pay for procedure code H0018 billed for date of service June 9, 
2023, to June 15, 2023. 
 
You asked the Plan to pay for procedure code H0018. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code H0018 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0018 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0018 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0018 billed for date of service June 9, 2023, to June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on June 15, 2023, billed with 
codes 87481, 87500, 87640, 87641, 87653, and 87798. 
 
You asked the Plan to pay for the billed testing. You say that the panel should be covered. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage of the billed testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the panel testing provided on June 15, 2023, billed with codes 87481, 87500, 87640, 87641, 87653, and 
87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service July 10, 
2023. 
 
You asked the Plan to pay for procedure code 96040. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 96040 is considered bundled 
and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 96040 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96040 billed for date of service July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing billed with 
codes 87798, 87481, 87500, 87640, 87653, and 87641 provided on July 5, 2023. 
 
You asked the Plan to pay for the urine PCR testing. 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 a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Review of the file shows that the urine PCR testing at issue was 
unbundled. A panel should be billed with one code. This service is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the urine PCR testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing 
billed with codes 87798, 87481, 87500, 87640, 87653, and 87641 provided on July 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13121 for date of service May 18, 2023. 
 
You asked the Plan to pay for procedure code 13121. 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 13121 is repair, complex, scalp, arms, and/or legs; 2.6 cm 
to 7.5 cm. 
 
We find that CPT code 13121 is not supported in the medical record. Specifically, the documentation indicates 
that Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm 
to 7.5 cm, was performed. This means there is a more appropriate code to be billed for the services rendered. 
Based on this information, we decided that Medicare rules for coverage of procedure code 13121 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 13121 for date of service 
May 18, 2023.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can be provided 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: 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 over 3 hours of physical and 
occupational therapy services per day with physician oversight. The Plan denied your request. The Plan says 
based on the available information, admission to IRF is not reasonable and necessary, as the enrollee's 
condition does not meet these Medicare rules.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can be provided 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: 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 for you as you 
were independent before your hospitalization and want to return to being independent. 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 the intensity of services provided at an IRF. You are not shown to 
require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician 
evaluation. Your care needs can be met 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guidance Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that your provider says IGRT is necessary and is not 
recommending Mohs surgery for it because of the location of cancer on your skin. The Plan denied your 
request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed or 
effective for your skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the type of radiation therapy guidance requested is not needed or effective for this type of skin 
cancer. It is not considered standard 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guidance Radiation Therapy (IGRT) (G6001).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that an auto EPAP mode can provide the 
enrollee with a range of necessary pressure settings to manage their severe respiratory condition. The Plan 
denied your request. The Plan says that a home ventilator is not medically necessary for this patient because 
their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
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 system. Our reviewer 
says that a home ventilator system is medically necessary. Our physician reviewer found that the enrollee is 
already prescribed and are using a home ventilator, trilogy. Therefore, it would be considered substandard of 
care to deny the enrollee a therapy they are already on and using. 
 
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 system have been met. Therefore, we decided that the Plan 
has to pre-approve a home ventilator system.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary to 
ensure a safe environment to meet your needs. The Plan denied your request. The Plan says you are receiving 
appropriate inpatient acute care and do not require transfer to a LTACH. 
 
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 there is no therapeutic benefit to LTACH transfer. Your needs are being met in the 
current setting until you can be transferred to a lower level of care such as a skilled nursing facility. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records indicated that the enrollee has 
a history of a memory impairment in the setting of depression. There was no indication that the enrollee met 
diagnostic criteria for either AD or FTD, let alone both conditions. In such a setting/context, the base 
requirement of the NCD would not be met. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601), provided on June 22, 2023. 
 
You asked the Plan to pay for the CPAP device. You say that the item was medically necessary. 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 record does not contain a valid proof of delivery for the supplies provided in this case. There was not a 
delivery slip or itemized packing slip included in the documents submitted. 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 the continuous positive airway pressure (CPAP) device (E0601), provided on 
June 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 26, 2023, billed with 
codes 87798 and 87481. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing detects viral targets. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This NGS panel was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 26, 2023, 
billed with codes 87798 and 87481.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee feels more SNF services are needed. 
The Plan denied your request. The Plan says medical records do not support the need for continued SNF 
services, and the enrollee's needs can be provided at another level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 has been bed and chair ridden for three 
weeks since being admitted to the hospital leaving them requiring intense physical therapy services. The Plan 
denied your request. The Plan says the enrollee's records show that it is not reasonable to expect that they will 
be able to safely participate in or fully benefit from the intensity of services of 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee does require treatment by multiple therapies. Therapy documentation dated October 26, 
2023, indicated that the enrollee required moderate assistance with bed mobility, minimal to moderate 
assistance with transfers and walking with a walker. The enrollee requires moderate to maximum assistance 
with daily activities, including dressing and toileting. The enrollee has had a significant decline from their 
baseline level of function and would benefit from the intensity of therapies provided on acute inpatient 
rehabilitation. 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.