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

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the services are medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does meet criteria for acute inpatient mental health treatment as this 
enrollee was shown to be a danger to herself but not others. She had auditory hallucinations, but no visual 
hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urinary tract infection (UTI) panel (87798 and 87481) 
provided on May 11, 2023. 
 
You asked the Plan to pay for a UTI panel. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this panel was not reported in accordance with 
Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a urinary tract infection (UTI) panel (87798 and 87481) provided on May 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the enrollee needs this item to get on and 
off the toilet without assistance. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine lab panel provided on December 7, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine lab panel provided on December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87798, 87481, 
87640, and 87653 for date of service August 1, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87798, 87481, 87640, and 87653. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the amplified probe 
technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in 
this case. As such, a single code with one unit of service should be used. Based on this information, we decided 
that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with codes 87798, 87481, 87640, and 87653 for date of 
service August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment, cervical, free-standing stand/frame, 
pneumatic, applying traction force to other than mandible (E0849) provided May 2023. 
 
You asked the Plan to pay for the traction equipment. You say that please see attached medical records. The 
Plan denied your request. The Plan says this service is not covered for this procedure.  
 
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 traction equipment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found presented for an office visit with low back pain for one week. A request was made 
for traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than 
mandible (E0849) to be used to "restrict mobility and provide support." However, the documentation no 
cervical spine examination findings. The documentation does not clearly show that the enrollee has a 
musculoskeletal or neurologic impairment requiring traction equipment to support this request. Therefore, the  
LCD criteria is 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 traction equipment have not been met. Therefore, we decided that the Plan 
does not have to pay for the traction equipment, cervical, free-standing stand/frame, pneumatic, applying 
traction force to other than mandible (E0849) provided May 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 26, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the codes billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 26, 2023.
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 for 
the enrollee to regain their maximum prior level of function and continue a multi disciplinary approach to care. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an 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 evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred or 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on February 27, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on February 27, 2023.
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. The 
Plan denied your request. The Plan says the records do not show that the enrollee's ongoing care needs can only 
be met in the hospital. 
 
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 enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred or 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment, cervical, free-standing stand/frame, 
pneumatic, applying traction force to other than mandible (E0849) provided May 21, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that please see attached medical records. The 
Plan denied your request. The Plan says this item or service does not meet the criteria for the category under 
which it was billed.  
 
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 traction equipment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with chronic cervical stenosis, cervical myelopathy who was reported as 
having head trauma due to being pulled from a wheelchair by their dog who was walking on a leash. The 
enrollee's cervical spine was noted as rigid, but not tender. A request was made for traction equipment, 
cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible (E0849). A 
magnetic resonance imaging (MRI) was ordered, but the traction device was not noted as ordered or part of the 
plan in the documentation provided. Therefore, the criteria is not met for this device, and it will be considered 
not medically necessary based on the provided documentation. 
 
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 traction equipment have not been met. Therefore, we decided that the Plan 
does not have to pay for the traction equipment, cervical, free-standing stand/frame, pneumatic, applying 
traction force to other than mandible (E0849) provided May 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service June 6, 2023. 
 
You asked the Plan to pay for procedure code 99135. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99135 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 99135 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99135 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99135 billed for date of service June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service May 1, 2023. 
 
You asked the Plan to pay for procedure code 12001. The Plan denied your request. The Plan says payment for 
code 12001 is bundled into payment for code 28490.  
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 12001 
is a column II code to column I code 28490. 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 12001 billed for date of 
service May 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 21, 2022, billed with 
codes 81162, 81292, 81295, 81298, 81317, 81321, 81405, 81406, 81408, 81307, 81403 and 81201. 
 
You asked the Plan to pay for the genetic testing 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 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 was an NGS 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 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 21, 2022, billed with codes 81162, 81292, 81295, 81298, 81317, 81321, 81405, 81406, 81408, 81307, 
81403 and 81201.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third spinal level of facet joint injection. 
 
You asked the Plan to pre-approve a third spinal level of facet joint injection. You say that the requested 
service is medically necessary to treat the enrollee's lower back pain. The Plan denied your request. The Plan 
says the requested additional level does not meet the necessary criteria for approval. 
 
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 a third spinal level of facet joint 
injection. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, there is no documentation as to why a three-
level procedure is indicated. Per guidelines, research has shown that three diagnostic levels are not routine and 
would be under unusual circumstances. The review has determined that the enrollee does not meet the LCD 
criteria for coverage. 
 
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 3rd spinal level of facet joint injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a third spinal level of facet joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on June 
26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that  The Plan denied your request. The Plan 
says OTC COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for OTC items, including 
self-administered COVID-19 tests. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on June 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (31257, 31267) provided on May 9, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that claims reporting at least one J1 procedure code 
will package lower ranked comprehensive procedure codes with status indicator J1.  
We looked at the file and Medicare rules. The claim in this case was billed with code 31276 which has status 
indicator J1 and has been paid. As codes 31257 and 31267 also have status indicator J1, these codes are 
considered packaged with code 31276, and are not separately payable. 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 the services (31257, 31267) provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the remote therapeutic monitoring services coded as 98975 billed on 
date of service June 15, 2023. 
 
You asked the Plan to pay for 98975. You say that 98975 should be paid as billed because it was a distinct 
service not bundled into any other service. The Plan denied your request. The Plan says that payment for 98975 
is included in payment for code 98977 performed on the same date, and no modifier was appended. 
 
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 denial reason cited by the Plan is not sufficient in this case 
because there is no rule prohibiting 98975 and 98977 from being reported together. There is no National 
Correct Coding Initiative (NCCI) edit between these two codes, so no NCCI modifier would be required for 
coverage of 98975 in this case. There is nothing inherent about the code definitions of 98975 and 98977 that 
would make them mutually exclusive. Therefore, we decided that the Plan has to pay for the remote therapeutic 
monitoring services coded as 98975 billed on date of service June 15, 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.