Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the medical records provided support the 
need for the requested home ventilator.  The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for the enrollee because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee has severe 
COPD. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee was 
hospitalized in July 2023 with COPD exacerbation, and blood gases were consistent with acute on chronic 
hyper carbic respiratory failure. The enrollee was apparently prescribed BiPAP ST at pressures of 20/10 on 
discharge from the hospital. The enrollee was seen in pulmonary follow-up on November 2, 2023, and 
appeared to be stable. Compliance with BiPAP use was good. There was no documentation of failure of BiPAP 
as an outpatient. A home ventilator was prescribed on November 8, with a note that the enrollee failed BiPAP. 
The ventilator is ordered in the AVAPS-AE mode, which can be provided with BiPAP. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 59, 87491 59, 87563 59, 87640 59, 
87653 59, 87798 59, 87641 and 87500 billed for July 12, 2023. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. 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 procedure codes 87481 59, 87491 59, 87563 
59, 87640 59, 87653 59, 87798 59, 87641 and 87500 billed for July 12, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care. 
 
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 medical 
records support 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. It 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: 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 are in home care but need IRF services to regain 
your prior level of functioning and independence. The Plan denied your request. The Plan says the request is 
not medically 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 are unable to move on my own without help, and 
your overall healing process will be delayed without an IRF admission. The Plan denied your request. The Plan 
says the request is not medically 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on June 14, 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 the submitted medical records do not indicate the intra-service time for the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 in this case, there were no 
anesthesiology records submitted documenting intra-operative monitoring of this patient (including blood 
pressure, heart rate, respiratory rate, EKG, oxygen saturation) or medications administered. The review has determined that the use of CPT 99152 is not supported by the records provided.  
 
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 moderate sedation services (procedure code 99152) rendered on June 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each mammogram provided on July 19, 
2023. 
 
You asked the Plan to waive the coinsurance for each mammogram. You say that the services should be 
reprocessed at the in-network benefit level. 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 40% 
coinsurance for out-of-network breast cancer screening. 
 
You have been asked to pay 40% coinsurance for each mammogram. This item/service falls within the out-of-
network breast cancer screening 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 coinsurance for 
each mammogram provided on July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. 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, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87186 billed for date of service July 12, 
2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code is 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 87186 is susceptibility studies, antimicrobial agent; 
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-
antimicrobial, per plate. 
 
We find that CPT code 87186 is not supported in the medical record. The records provided do not show that 
this service was performed. Based on this information, we decided that Medicare rules for coverage of the 
billed service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
87186 billed for date of service July 12, 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 enrollee is now stable, and admission 
is medically necessary. The Plan denied your request. The Plan says the records do not show the enrollee has 
finished the current acute hospital care. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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 pre-approve Image Guidance Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed or 
effective for the enrollee's skin cancer. Therefore, it not considered standard of care. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually, IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can 
be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general) is not necessary. The decision is 
unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guidance Radiation Therapy (IGRT) (G6001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 27, 2023. 
 
You asked the Plan to pay for lab tests. You say that you do not have access to physician notes and reports. The 
Plan denied your request. The Plan says the record references a different Clinical Laboratory Improvement 
Amendments (CLIA) identification number than the claim form, so the location where the services were 
performed cannot be verified. 
 
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 85025 is blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. The CPT Code Manual definition 
of code 80048 is basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total 
(82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) 
Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520).  
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found although the lab report supports the procedures reported, the Clinical 
Laboratory Improvement Amendments (CLIA) identifier cannot be verified. On the claim the CLIA is reported 
as 10D2145635, but on the lab report the CLIA is 25D22584404. The documentation includes conflicting 
CLIA number and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on June 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31500 provided on June 26, 2023. 
 
You asked the Plan to pay for procedure code 31500. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 31500 is not supported in the medical record. Specifically, the records show the service 
was performed on June 27, 2023. The date of service on the claim is June 26, 2023. Based on this information, 
we decided that Medicare rules for coverage of procedure code 31500 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 31500 provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 5, 2023. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the panel provided in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says based on the current medical literature, this procedure is not considered the 
standard of care for management of chronic knee pain. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is considered experimental therapy and is the subject of ongoing clinical 
trials. Therefore, the request is deemed 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular artery embolization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 15 units of procedure code 88342 performed on August 21, 
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 there was no documentation of a medically necessary reason for the extra units. 
 
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 88342 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 
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 underwent gastric 
and duodenal biopsy via endoscopy procedure on 8/21/23. Documentation shows 4 samples (units) were 
processed. There was no documented explanation as to why 15 units were requested for coverage in this 
instance to support this request. The records do not support that the additional units beyond 4 units were 
actually rendered or that they would be reasonable and necessary.  
 
 
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 15 units of procedure code 88342 performed on August 21, 2023.