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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
admission to an LTACH and cannot be adequately cared for in their current condition at a skilled nursing 
facility. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the enrollee does not meet all the requirements for admission 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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious-agent testing (87798) provided on February 9, 2023. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 has not provided a copy of the claim at issue. Based on the 
present case record, we are unable to confirm the Plan's denial rationale. It is the Plan's responsibility to support 
its denial with evidence. In this case, the Plan has not supported its denial, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for infectious-agent testing (87798) provided on February 9, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order 
to receive reimbursement from Federal programs.  
 
We looked at the file and Medicare rules. The file shows that the claim was billed with a different CLIA 
number than the CLIA number on the laboratory results. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on December 30, 2022.
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 August 9, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 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 August 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries; complete bilateral 
study (93880) provided March 10, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the diagnosis codes should not be reported together which is based on the Excludes1 Notes 
instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The diagnosis codes associated 
to I65.29 (Occlusion and stenosis of unspecified carotid artery) and G45.9 (Transient cerebral ischemic attack, 
unspecified), should not be reported together per the 2023 ICD-10-CM Tabular. The billed service has been 
denied because it was reported with one or more diagnosis code pairs that are subject to an Excludes1 note. 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. 
Therefore, we decided that the Plan does not have to pay for the duplex scan of extracranial arteries; complete 
bilateral study (93880) provided March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for and pay for an outpatient hospital stay and 
self-administered drugs from July 20, 2023, to July 22, 2023. 
 
You asked the Plan to waive the copayment for and pay for the outpatient stay and drugs. You say that the 
claim processed incorrectly. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Outpatient Hospital Observation.  
 
You have been asked to pay a $325 copayment for the outpatient stay. This item/service falls within the 
Outpatient Hospital Observation benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an outpatient hospital stay from July 20, 2023, to July 22, 2023.  
 
You have also been asked to pay $226 for self-administered drugs during your stay. The Plan must follow 
Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The 
self-administered drugs requested here are not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pay for self-administered drugs from July 20, 2023, to 
July 22, 2023. 
 
Benefits for the outpatient stay and drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Infliximab test. 
 
You asked the Plan to pre-approve the Infliximab test. The Plan denied your request. The Plan says this is 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 pre-approve the Infliximab test. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records document the enrollee is being treated with Infliximab 7.5 mg/kg every 6 
weeks and is "Doing well overall" at his most recent office visit. Prior Infliximab testing from February 22, 
2023, reported a level of 7.2 micrograms/mL and no antibodies. The records do not document any subjective or 
objective changes in the enrollee condition to necessitate the requested testing.  
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 Infliximab test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Infliximab test.
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 20, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 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 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid (DNA or 
RNA) (87637) provided January 10, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that the medical records provided will show proof 
of medical necessity The Plan denied your request. The Plan says medical necessity cannot be established due 
to insufficient information submitted. 
 
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 the laboratory testing have been met. 
The records show that the Plan made multiple attempts to obtain the needed medical records without success. 
Therefore, we decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid 
(DNA or RNA) (87637) provided January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept 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 this does not meet the requirements 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease. The cause of pain is not clear. 
 
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 Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481) provided April 5, 2023. 
 You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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 G0481 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. The submitted laboratory requisition 
indicates that oral swab profile panel was requested. The submitted documentation does not itemize what tests 
are included in this panel. Therefore, the billed service cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing (G0481) provided April 5, 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 July 25, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 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 July 25, 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 he enrollee needs the continuation of 
intravenous antibiotics for pneumonia, new hemodialysis, cardiac, blood pressure, and respiratory support, 
close medical monitoring with daily physician involvement. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home with home health, or 
outpatient therapy. 
 
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 that at the time of the request for LTACH services, the enrollee requires telemetry, respiratory therapy, supplemental oxygen at 2-3L, hemodialysis, frequent lab and physician visits, and therapy, 
all of which can be safely done in the current acute care setting. There is no documentation indicating medical 
necessity for admission to a LTACH.The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he/she is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0201 billed for date of service May 29, 
2023, to June 2, 2023. 
 
You asked the Plan to pay for procedure code S0201. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S0201 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0201 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0201 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0201 billed for date of service May 29, 2023, to June 2, 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 he continuation of medically necessary 
acute care services at an LTACH is medically appropriate based on the Centers for Medicare and Medicaid 
criteria. The Plan denied your request. The Plan says the enrollee's needs are being met at the current hospital 
location. 
 
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 that in this case the enrollee was admitted acute on chronic respiratory failure 
secondary to chronic obstructive pulmonary disease exacerbation. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services. The enrollee continues to receive acute care 
services and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not satisfied. The requested service cannot be recommended. 
 
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 Cxbladder test (0012M) provided on June 21, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on June 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9480 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for procedure code S9480. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9480 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9480 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9480 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9480 billed for date of service May 31, 2023.