Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. 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 January 29, 2023, to February 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
after June 19, 2023. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not ready for discharge due to 
ongoing medical issues. The Plan denied your request. The Plan says the continuation of the SNF level of care 
is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care after June 19, 2023.
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 LTACH services would improve the 
enrollee's opportunity and potential to return to their baseline. The Plan denied your request. The Plan says that 
the admission to a LTACH is not medically necessary. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 24, 2021. 
 
You asked the Plan to pay for the home health services. You say that the medical records support the billed 
Health Insurance Prospective Payment System (HIPPS) code of 3HC11. The Plan denied your request. The 
Plan says the records do not support the billed HIPPS code 3HC11. Instead, HIPPS code 3HC11 was paid. 
 The Plan follows Medicare rules. Medicare rules say that providers must bill services correctly. 
 
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 home health services. Our reviewer says 
that the HIPPS code billed is not supported. Our physician reviewer found the enrollee was only on two 
medications and at a moderate risk of hospitalization.  As a result, the Plan's adjusted code more accurately 
reflects the enrollee's condition. 
 
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 health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided on November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the RFA of the liver (47382) provided on August 2, 2022. 
 
You asked the Plan to pay for the RFA. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says that this procedure was 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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician  
 reviewer found that the clinical documentation is insufficient to demonstrate that RFA of the liver is indicated 
for the enrollee in this case. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pay for the RFA of the liver (47382) provided on August 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins including responses to 
compression and other maneuvers; complete bilateral study rendered on December 10, 2022. 
 
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 records do not support the services billed. 
 
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 93970 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study." 
 
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 procedure report describes 
duplex scan bilateral extremities, and in this case there is a more appropriate code to report for service 
provided. Modifier 76 is inappropriate, as procedure was performed on different anatomical area of the body, 
and is not considered a repeat procedure. 
 
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 duplex scan of extremity veins including responses to compression and other maneuvers; 
complete bilateral study rendered on December 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve ten additional sessions of hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve the additional sessions. You say that authorization should be approved for 
additional sessions. The Plan denied your request. The Plan says that the requirements have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
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 additional sessions. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that osteoradionecrosis can cause significant disability. Many oral surgeons and radiation 
oncologists prescribe hyperbaric oxygen (HBO) to prevent and/or treat osteoradionecrosis in patients with 
previous significant radiation therapy exposure to the mandible. Treatment typically requires 30 to 40 sessions 
("dives") delivered once or twice daily, generally for five days a week and thus lasting up to eight weeks. The 
enrollee has not yet achieved this number of sessions. The service is reasonable and 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 additional sessions have been met. Therefore, we decided that the Plan has 
to pre-approve ten additional sessions of hyperbaric oxygen therapy (HBOT).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax provided on March 6, 2023. 
 
You asked the Plan to pay for the sales tax . You say that you should not be responsible for the $5.55. You say 
this is a tax that should be imposed on the provider and not the patient. The Plan denied your request. The Plan 
says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when up to a $350 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $350 towards the vision services, which 
exhausted the benefit. Please note, the Plan originally issued payment in the amount of $346.60 and upon 
review issued an additional $3.40 for a total of $350. Based on this information, we decided that the Plan's 
rules for coverage of the sales tax has not been met. Therefore, we decided that the Plan does not have to pay 
for the sales tax provided on March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 18, 2022, to 
November 19, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly. The Plan denied your request. The Plan says that the principal diagnosis code A41.9 is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the criteria for coverage have been met.  Our 
physician reviewer found the enrollee did not have evidence of pneumonia or prior diagnosis of decreased 
oxygenation. Pulse oximetry is a valid measure of oxygenation and a valid means of monitoring oxygenation 
status. The enrollee's condition met Sequential Organ Failure Assessment (SOFA) criteria for sepsis with a 
score of 2. The hospital coded correctly 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on November 18, 2022, to November 19, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6219-GW billed for date of service January 
11, 2023. 
 
You asked the Plan to pay for procedure code A6219-GW. You say that these items were provided to the 
member to take home, so they should be separately paid. The Plan denied your request. The Plan says 
procedure code A6219-GW 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 A6219-GW has a status indicator of P on the Physician Fee Schedule. This means 
that procedure code A6219-GW is not separately payable. You did not bill with a modifier to indicate that this 
item is not incidental to the physician services performed. Based on this information, we decided that Medicare 
rules for coverage of procedure code A6219-GW have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code A6219-GW billed for date of service January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that ongoing skilled care can be provided in an alternative setting. 
 
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 the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered item or service, self-administered drugs 
(A9270) provided May 24, 2022. 
 
You asked the Plan to pay for the medication. You say that you do not believe that you should be responsible 
for this payment. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 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 the non-covered item or service, 
self-administered drugs (A9270) provided May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 22, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim was denied incorrectly. The Plan 
denied your request. The Plan says you billed these services with an incorrect pair of diagnoses. 
 
he Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of E11.621 and E08.621. Code E08.621 is an Excludes1 code 
under code E11.621, so these two diagnoses cannot be billed together. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 22, 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 it is unsafe for the enrollee to go home. 
The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 are no services available at the LTACH which the enrollee requires that are not 
available at the healthcare setting being offered by the Plan. The Plan has approved ongoing care in the current 
acute care setting. 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services 
 You asked the Plan to pre-approve home health services. You say that you have provided medical records to 
support this request. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has received skilled nursing since May 8, 2023. On the June 6, 2023, visit  his vital signs were stable and there 
were no recent changes in medication or treatment and the enrollee was not receiving any skilled intervention 
beyond repeat observation for a stable chronic condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health services
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs you received during outpatient 
hospital services provided from December 11, 2022, to December 13, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that these medications should be covered by 
your drug plan. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. You have submitted this request to your medical plan, not your drug plan. 
 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 you 
received during outpatient hospital services provided from December 11, 2022, to December 13, 2022.  
 
Benefits for the self-administered 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 pay for the pathogen detection by nucleic acid provided on 
September 19, 2022, billed with codes 87481, 87640, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing panel for pathogens. You say that this panel was medically 
necessary and should be paid. The Plan denied your request. The Plan says insufficient information was 
submitted to approve payment. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular panels for the detection of multiple 
pathogens should be billed with one unit of service for the panel.  
 
We looked at the file and Medicare rules. This multiple pathogen panel was not billed with a single unit of 
service. Based on this information, we decided that Medicare rules for coverage of the genetic testing panel for pathogens have not been met. Therefore, we decided that the Plan does not have to pay for the pathogen 
detection by nucleic acid provided on September 19, 2022, billed with codes 87481, 87640, 87651, 87653, and 
87798.