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 IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable and 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 enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The medical records do not support that the enrollee 
would meet criteria for admission to an acute inpatient rehabilitation facility. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 30 miles for a total of 80 miles 
transportation.  
 
You asked the Plan to pre-approve additional mileage. The Plan denied your request. The Plan says you have 
exceeded your benefit limit. This request is not covered by your health plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year, must not exceed 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 30 miles for a total of 80 miles transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on December 6, 2022, billed 
with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on December 6, 2022, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 
87640, 87651, 87798 and U0005.
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 patient requires an LTACH level of 
care, is stable for discharge, and clearly meets the LTACH criteria based on Medicare guidelines. The Plan 
denied your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 evidence that the patient requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the patient to the LTACH. The patient can remain at the current ACH until such time 
no acute services are required. Our reviewer also found that the patient can then be transferred/discharged to a 
lower level of care for any ongoing long term care needs. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2023, to March 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2023, to March 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service May 9, 2023. 
 You asked the Plan to pay for procedure code 93042. You say that you provided medical records showing that 
this service was provided during an emergency visit. The Plan denied your request. The Plan says payment for 
code 93042 is bundled into payment for code 93010. 
 
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, we have confirmed that code 93042 
is a column II code to column I code 93010. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service May 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service September 27, 2022. 
 
You asked the Plan to pay for code 99284. You say that this claim should be paid at the code billed. The Plan 
denied your request. The Plan says the records do not support the billing of code 99284. This claim was down-
coded to code 99282. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. 
 
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 code 99284. Our reviewer says that code 99284 is not supported by the medical record. Our reviewer found the enrollee is a 87 year old woman with a history of 
adenocarcinoma who presented with post-operative pain. In this case, the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level. As a result, 
code 99284 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 code 99284 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99284 billed for date of service September 27, 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 needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support the need for an IRF admission. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 10, 2023, to 
May 26, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely filed the required 
NOA. 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 May 10, 2023, to May 
26, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 22612, 63048, 63047, 
22842 and 22614. We decided that the Plan does not have to pay for the services described by procedure 
code(s) 20930.  
 
You asked the Plan to pay for services provided on June 12, 2023. You say that these services were necessary 
and are supported in the medical record. The Plan says that procedure code 20930 is considered bundled and 
not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 22612, 63048, 63047, 
22842 and 22614.  
 
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(s) 22612, 63048, 63047, 22842 
and 22614.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
20930. 
 
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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 20930 have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 20930. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for the billed services. You say that  routine testing is necessary to monitor 
prescriptions. The Plan denied your request. The Plan says the code cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left ventricular assistant device (LVAD) (33990, 
33991). 
 
You asked the Plan to pre-approve an LVAD. You say that this is medically necessary. The Plan denied your 
request. The Plan says documentation does not show the enrollee has significant heart pump problems. 
 
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 an LVAD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient documentation to support the medical necessity for LVAD placement in 
this enrollee's clinical management. 
 
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 LVAD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a left ventricular assistant device (LVAD) (33990, 33991).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and transport ready option for elevate (K0108).  
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and transport 
ready option for elevate. You say that when three or more power seating functions/actuators/motors are 
provided, one unit of E2311, one unit of E2377, and one unit of E2313 are allowed. You also say that the 
transport ready option is not an integral part of the base, thus a split decision should be possible. The Plan 
denied your request. The Plan says the requested transport ready option does not serve a medical need and 
cannot be covered. The Plan also says the electronic connection, harness, and expandable controller cannot be 
covered as it is not medically necessary to control the three requested power options through the joystick (drive 
interface). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has functional loss and has 
used a power wheelchair for many years. The enrollee can dress and feed themself. Our reviewer also found 
that the enrollee has sufficient upper strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. The transport ready option for elevate does 
not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare 
rules for coverage of an electronic connection, harness, expandable controller, and transport ready option for 
elevate have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and transport ready option for elevate 
(K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adipose stem cell therapy. 
 
You asked the Plan to pre-approve Adipose stem cell therapy. You say that you have had back pain since 2008. 
You say that you have had several surgeries and explored all options at this point. You also say that you feel 
this is your last option for pain relief. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Autologous Stem Cell Transplantation (AuSCT) 
is considered reasonable and necessary 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 Adipose stem cell therapy. Our 
reviewer says that the requested Adipose stem cell therapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that the enrollee has persistent chronic 
low back pain following spinal fusion. The noted indication is not one for which coverage is available under 
the rules. Therefore, the reviewer found that the requested Adipose stem cell therapy 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 Adipose stem cell therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Adipose stem cell therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 2, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.   
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 2, 2023, billed with 
code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 12, 2021. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and not medically 
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 pay for the urine PCR panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the standard of care for the evaluation of urinary incontinence is urinalysis with 
urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review 
has determined that the items/services at issue in this case are not medically reasonable and 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 the urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on July 12, 
2021.