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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. 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 (SNF) or at home with home health 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 enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service July 10, 
2023, to August 7, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim was filed timely. The Plan denied your 
request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim at issue was billed with two claim lines containing revenue code 
0023. Only one 0023 revenue code should be entered per claim in all cases Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the home health care billed for dates of service July 10, 2023, to August 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xG gene panel rendered on July 31, 2023. 
 
You asked the Plan to pay for the Tempus xG gene panel. 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 the Tempus xG gene panel is not covered.  
 
We looked at the file and Medicare rules. Review of the file shows that the testing at issue is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of the Tempus xG gene panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xG gene panel 
rendered on July 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0299, Q5001) provided on 
July 19, 2022, to August 17, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 19, 2022. The NOA was not received by the Plan until October 13, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0299, Q5001) provided on July 19, 2022, to August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would greatly benefit from acute 
rehabilitation and intensive therapies to return to their prior functional status. The Plan denied your request. 
The Plan says the IRF services requested do not meet the requirements for approval.  
 
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 enrollee's medical complexity does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive 
rehabilitation therapy, and it is unclear if they would tolerate the therapy in the IRF. There is not a reasonable 
expectation that the enrollee will be able to benefit from the intensive rehabilitation 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 willing to go to rehabilitation and do the 
work so you can regain maximum function in the shortest amount of time. You say you cannot go home in your 
current condition and you are unable to take care of yourself. The Plan denied your request. The Plan says the 
IRF services requested do not meet the requirements for approval.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although you need 
physical and occupational therapy and could tolerate the therapy in the IRF, the complexity of your condition 
doesnt require an IRF stay and care can be provided in a lower level.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36415, 84439, 84443, 85025, 80053, 83036, and 
80061 provided on June 6, 2023. 
 
You asked the Plan to pay for procedure codes 36415, 84439, 84443, 85025, 80053, 83036, and 80061. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says that the services are not covered as billed. 
 
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 Plan has not provided enough evidence to support their denial 
of payment for procedure codes 36415, 84439, 84443, 85025, 80053, 83036, and 80061 based on Medicare 
criteria. The codes at issue are not payable on the Physician Fee Schedule when they have a Professional 
Component (PC)/Technical Component (TC) indicator of "9" meaning that the concept of 
professional/technical components does not apply. This means that payment cannot be made for these codes 
when billed with the modifier 26. In this case, the claim shows that the procedure codes were not billed with a 
26 modifier. Therefore, we decided that the Plan has to pay for procedure codes 36415, 84439, 84443, 85025, 
80053, 83036, and 80061 provided on June 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 14, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the OIVIT services should be paid as billed 
because they are supported in the medical record. The Plan denied your request. The Plan says the OIVIT services are denied because they are not supported in the medical record and there is a more appropriate code 
for the services billed. 
 
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 14, 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 a lower level of care is not sufficient or safe to 
provide the enrollee with the ample services needed for optimal recovery. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, but skilled therapies as an outpatient or at a skilled 
nursing facility may be approved upon request.  
 
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 enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service September 
18, 2023. You asked the Plan to pay for procedure code 76705. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
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 76705 is a column II code to column I code 93976. Code 76705 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76705 
billed for date of service September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 04, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the copayment. 
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 $45 
copayment for physician/practitioner services. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the 
physician/practitioner services 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 office visit provided on April 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for lab services provided on September 27, 
2023. 
 
You asked the Plan to reduce the copayment for lab services. You say that you think that the copayment should 
be lower. 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 $35 
copayment for out-of-network lab services and diagnostic procedures/tests performed in an outpatient hospital 
facility. 
 
You have been asked to pay a $35 copayment for lab services. This item/service falls within the out-of-network lab services and diagnostic procedures/tests performed in an outpatient hospital facility 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 reduce the copayment for lab services provided on September 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70496 and 70498 billed for date of service 
August 3, 2023. 
 
You asked the Plan to pay for procedure codes 70496 and 70498. You say that this claim was denied in error. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 1, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure codes 70496 and 70498 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 70496 and 70498 billed 
for date of service August 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), expandable controller (E2377), and accent color (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller, and accent color. You say that you are requesting a formal mixed decision to independently review 
these items and issue formal determination in order to pursue other funding resources for these items. The Plan 
denied your request. The Plan says the electronic connection, expandable controller harness, and expandable 
controller cannot be covered as it is not medically necessary to control the three requested power options 
through the joystick (drive interface). The Plan also says that an accent color does not serve a medical purpose 
and cannot be approved 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, expandable 
controller harness, and expandable controller, and accent color. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has multiple sclerosis (MS) and impaired ambulation. The enrollee is able to walk short 
distances with a walker and has 5 out of 5 strength in their upper extremities. Our reviewer also found that this 
request is not medically necessary as the enrollee has adequate strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. The accent color issue in this appeal does not 
serve a purpose that is primarily medical in nature. This item is available to the general public and would be 
helpful even to those who are not sick or injured. Based on this information, we decided that Medicare rules for 
coverage of an electronic connection, expandable controller harness, and expandable controller, and accent 
color have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), expandable controller (E2377), and accent color 
(K0108).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on June 6, 
2022, through June 28, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 7, 2022. The NOA was not received by the Plan until November 15, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0299, 
Q5001) provided on June 6, 2022, through June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test was medically necessary. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 30, 2022.