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

 
We decided that the Plan does not have to pay for laboratory services rendered on December 13, 2022. 
 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87571, 87640, 87651, 87798, and U0005 
are not supported in the medical record. Specifically, this panel should have been reported with only one 
comprehensive code. 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 rendered on 
December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) and 
accessories/multiple power options. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical need for the multiple power options included with the K0861 group 
3 power wheelchair. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee has a neurologic disorder with functional deficits. The documentation does 
not indicate that the member has any pressure injuries or requires intermittent catheterization of the bladder or 
have spasticity that would necessitate power tilt or recline. Although the enrollees condition may meet criteria 
for a PWC, the criteria for this specifically requested PWC with multiple power options including power tilt 
and recline are not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair (PWC) and accessories/multiple power options.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88311 billed for date of service April 4, 
2023.  You asked the Plan to pay for procedure code 88311. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88311 is 4. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88311 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88311 billed for date of service April 4, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for date of service May 3, 
2023. 
 
You asked the Plan to pay for Breast Cancer Index testing. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that laboratory services must be 
reported with the date of specimen collection as the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be billed 
with the date of service as the date the specimen was collected. However, there are exceptions to this rule.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have been met. Specifically, the record shows that the sample in 
question is tissue which would have been obtained in a medically necessary hospital stay, and the test was 
performed after discharge. This means that an exception to the general rule has been met, and it would be most 
appropriate to report the date the test was reported as the date of service. In this case, the appropriate date is 
May 3, 2023. Therefore, we decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for 
date of service May 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) 
services provided on March 22, 2023. 
 
You asked the Plan to pay for the OIVIT services. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically reasonable and necessary, and therefore are not covered. Based on this information, we decided that Medicare 
rules for coverage of the OIVIT services have not been met. Therefore, we decided that the Plan does not have 
to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) services provided on March 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivaer procedure. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature does not support this service to be reasonable 
or necessary. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has nasal congestion secondary to obstruction from 
alar collapse. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vivaer procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve an ILR device. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records do not show that the enrollee has had a cryptogenic stroke 
or that a Holter monitor or another noninvasive cardiac monitor contraindicated or results indeterminate. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 an ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found this device is not indicated 
in the above individual with no history of unexplained syncope, or Cryptogenic stroke does not benefit from 
this device. Therefore, the reviewer found that the requested ILR device 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 an ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) device.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has pay for the inpatient services rendered on January 21, 2023, through February 3, 
2023. 
 
You asked the Plan pay for the inpatient services. You say that the inpatient services should be covered because 
principal diagnosis A41.51, defined as sepsis due to Escherichia coli, is supported in the documentation. The 
Plan denied your request. The Plan says that diagnosis A41.51 is not supported in the record. 
 
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 file did not include full medical records for the enrollees inpatient stay. The 
file includes evidence that there was a pre-payment request for records, and that those records were received 
and reviewed prior to the claim denial. The case file does not include a dated copy of the records received 
during that pre-payment review. Without all records that the Plan received, we cannot confirm whether the 
Plans denial rationale is correct. Therefore, we decided that the Plan has pay for the inpatient services rendered 
on January 21, 2023, through February 3, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetics (L5301, L5620, L5629, L5645, L5637, 
L5781, L5679, L5910, L5940, L8420, L8470, L8440, L5981) to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve prosthetics. You say that your provider accidently picked the wrong location 
and was not aware that the facility was OON. You would like to receive your equipment from this vendor since 
they already have your measurements, and the items are ready. The Plan denied your request. The Plan says 
you must receive your care from a network provider. There are in-network providers available for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
prosthetics (L5301, L5620, L5629, L5645, L5637, L5781, L5679, L5910, L5940, L8420, L8470, L8440, 
L5981) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from August 23, 
2022, to August 26, 2022. 
 
You asked the Plan to pay for SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the necessary documentation was not submitted to support the per diem 
payment rate billed. 
 
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 SNF care have been met. The records 
submitted do not include the MDS assessment for this resident. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from August 23, 2022, to August 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from October 11, 2022, to 
November 7, 2022. 
 
You asked the Plan to pay for home health care. You say that the Plan has not provided any means of submitted 
the Notice of Admission (NOA). The Plan denied your request. The Plan says the required Notice of 
Admission (NOA) was not 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. The 
required Notice of Admission (NOA) was not submitted to the Plan. Therefore, we decided that the Plan does 
not have to pay for home health care provided from October 11, 2022, to November 7, 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 you need to regain strength and optimal function. 
The Plan denied your request. The Plan says your condition does not meet the criteria for an IRF admission and 
your medically necessary care can be provided in an alternate setting.  
 
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 were admitted for lumbar spinal surgery. Your medical problems are stable and 
there are no complex nursing or rehabilitation needs. 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services reported with DRG 291 rendered from June 
29, 2022, to July 1, 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 that 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 291. 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 supported by the medical records. Our physician reviewer found that 
diagnosis code I50.33 is supported based on the x-ray, physical exam, treatment plan, and brain natriuretic 
peptide (BNP) test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services reported with DRG 291 rendered from June 29, 2022, to July 1, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure code 0326U) rendered on February 7, 
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 that the denied code 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 0326U is "Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA 
analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene 
rearrangements, microsatellite instability and tumor mutational burden." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee had GuardianDx testing 
performed for an invasive melanoma sample. The documentation does therefore support CPT 0326U in this 
case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services (procedure code 0326U) rendered on February 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a drug test provided on April 21, 2023. 
 
You asked the Plan to pay for the office visit and drug test. You say that the provider is in-network with the 
Plan. The Plan denied your request. The Plan says the Plan requires utilization of network providers when 
possible and available and requires authorization for certain services. No medical necessity for an out-of-
network provider such as an urgent or an emergent situation that has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit and a drug test provided on April 21, 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 provider states the enrollee needs at least three 
hours of physical therapy a day. The Plan denied your request. The Plan says the enrollee's condition does not 
meet the Medicare rules 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 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.