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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show 
that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that 
the enrollee must have an intensive therapy program (3 hours a day, at least 5 days a week) in order 
to improve self-care functioning.  
 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. There are no complex nursing or rehabilitation needs.  The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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. 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: Imaging
Decision: Favorable

 
We decided that the Plan has  to pay for the radiologic examination (x-ray) of the toe(s) (73660) provided on 
April 17, 2023. 
 
You asked the Plan  the x-ray. You say that the service was billed correctly and should be paid. The Plan 
denied your request. The Plan says that there was a National Correct Coding Initiative (NCCI) edit with code 
73660. In order to bypass the edit, code 73660 would need to be billed with an anatomical modifier. Code 
73660 was not billed with a modifier that can bypass the edit. 
 
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. We find that the Plan hasnt provided a valid denial rationale, to justify the 
denial of code 73660. The Plan is citing NCCI rules but there was no Column 1 code billed. Therefore, we 
decided that the Plan has to pay for the radiologic examination (x-ray) of the toe(s) (73660) provided on April 
17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29581 and 11043 billed for date of service 
June 2, 2023, to July 31, 2023.  
 You asked the Plan to pay for procedure codes 29581 and 11043. You say that you disagree with the Plan's 
denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 29581 and 11043 is 1. The MAI value for this code is 2. You billed 3 
units of code 29581, and 4 units, 2 units, and 2 units of code 11043, exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 29581 and 11043 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 29581 and 11043 billed for 
date of service June 2, 2023, to July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 17, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. 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. Specifically, there was no signed receipt of the delivery. 
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 supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 17, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code 88112. We decided that the 
Plan does not have to pay for the services described by procedure code 88121.  
 
You asked the Plan to pay for the lab services billed for date of service May 12, 2023. The Plan says that an 
inappropriate place of service was billed. 
 
We decided that the Plan has to pay for the services described by procedure code 88112.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code 88112.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 88121. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 
the services described by procedure code 88121. 
 
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 were rendered from June 1, 2023, 
Through June 30, 2023. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
claim was billed with an invalid type of bill for a non-participating home health provider as the type of bill 
(TOB) on the claim is submitted as "0323" which is incorrect and should be "329" and required Q code is not 
billed. We find the Medicare rule for payment of this June 01, 2023, through June 30, 2023, claim has not been 
met. Based on this information, we decided that Medicare rules for coverage of the home health services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services were 
rendered from June 1, 2023, Through June 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) of the thorax 
(71271) provided on August 4, 2023. 
 
You asked the Plan to pay for the LDCT. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says code 71271 is not supported because they were billed with an 
inappropriate diagnosis code. 
 
The Plan must follow Medicare rules. Claims for 71271 will be denied if not billed with certain diagnosis 
codes. 
 We looked at the file and Medicare rules. In this case, the claim was not billed with one of the required 
diagnosis codes listed in the Medicare rules section. Based on this information, we decided that Medicare rules 
for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for 
the low dose computed tomography (LDCT) of the thorax (71271) provided on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on June 13, 
2023. 
 
You asked the Plan to pay for the complete denture. You say that you accept that the implant services are not 
covered; however, you feel the complete denture should be paid for by the Plan. The Plan denied your request. 
The Plan says the complete denture was not reported properly in this case, as the item at issue would be an 
implant-supported denture. An implant-supported denture is not covered as it is a service which relates to 
dental implants. 
 
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. The rules say that providers must report services correctly. Providers must 
report services with the correct CPT code. In addition, Medicare generally does not cover dental services. 
However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage 
rules apply in this case. 
 
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 the complete denture have been met. 
Specifically, the limited records provided do not provide any details to describe the denture provided in this 
case. However, the records show that dental implants were performed for teeth #6 and #11, which are in the 
upper jaw. This documentation suggests that a complete denture described by code D5110 could not have been 
provided, and the denture in this case relates to or relies on support from these implants. It appears that an 
implant-supported denture was provided in this case, which is not covered by the enrollees dental benefit. 
Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) provided on 
June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for placement of a nephroureteral catheter provided on July 26, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for practitioner services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that their original decision to deny payment was correct. 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for placement of a nephroureteral catheter provided 
on July 26, 2023, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 7, 2022, to 
March 24, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. 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 February 5, 2022. The NOA was not received by the Plan until November 
15, 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 the home health services 
provided from March 7, 2022, to March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on August 4, 2023. 
 
You asked the Plan to pay for the testing billed. You say that the results directly impact clinical decision 
making. 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. The panel testing at issue was billed with codes 81432 and 81433. 
The Plan has agreed to pay for code 81432. The NGS panel at issue was not billed with a single code as 
required. 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 further pay for the panel testing provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility discharge management (procedure code 
99316) rendered on May 25, 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 99316 (1 Unit) 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 99316 is "Nursing facility discharge management; more 
than 30 minutes total time on the date of the encounter." 
 
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 not supported by the medical records. Our reviewer found that the enrollee enrollee was 
evaluated in a long term care (LTC) facility and eventually sent to the hospital for evaluation.  None of the 
documentation notes that the enrollee was actually discharged from the LTC. None of the documentation notes 
the amount of time spent discharging the enrollee.  As such, the billing of CPT 99316 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for nursing facility discharge management (procedure code 99316) rendered on May 25, 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 enrollee is 86 and having quadruple bypass. You 
also say that a different place for therapy than what was approved is needed. The Plan denied your request. The 
Plan says based upon the careful review of all submitted clinical information the enrollee does not meet 
Medicare coverage guidelines.  
 
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 
was admitted for coronary artery  disease and coronary artery bypass grafting. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code 99291. We decided that the 
Plan does not have to pay for the services described by procedure code 99053.  
 
You asked the Plan to pay for procedure codes 99291 and 99053 billed for date of service July 23, 2023. You 
say that 99291 and 99053 should be paid as billed because they are supported in the medical record and were 
medically necessary. The Plan says that 99291 is being handled as an original decision reopen for New and 
Material Evidence, therefore no coverage decision has been made. 99053 is denied because it is considered 
bundled and not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code 99291.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code 99291.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99053. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services with the appropriate 
procedure code. The rules also say that no separate payment is made for codes with a Status Indicator of B on 
the Physician Fee Schedule.  
 
We looked at the file and Medicare rules. We find that procedure code 99053 has a status indicator of B on the 
Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code 99053 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code 99053. 
 
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.