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 the enrollee's current condition and functional 
deficits, as well as multiple comorbidities, meets full Inpatient Acute Rehabilitation criteria. The Plan denied 
your request. The Plan says inpatient rehabilitation is not medically necessary; care could be given at a skilled 
nursing facility. 
 
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. 
 
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 home health services provided from June 11, 2022, to July 
10, 2022. 
 You asked the Plan to pay for the home health services. You say that you thought the patient had Original 
Medicare instead of a Medicare Advantage plan. The Plan denied your request. The Plan says the NOA was not 
received. 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, you have not submitted the required NOA.  As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from June 11, 
2022, to July 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 6, 2022, to 
February 7, 2022. 
 You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. 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 January 6, 2022. The NOA was not received by the Plan until March 28, 
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 provided 
from January 6, 2022, to February 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
March 29, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says the billed codes are 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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IMRT for bladder cancer.  
 
You asked the Plan to pre-approve IMRT. You say that IMRT is medically necessary. The Plan denied your 
request. The Plan says the radiation treatment requested is not appropriate for treatment of bladder cancer. 
 
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 IMRT. Our reviewer says that the 
requested IMRT is not considered medically reasonable and necessary. Our physician reviewer found the 
enrollee with clinical stage T2N1 bladder cancer (high-grade urothelial carcinoma invading the muscularis 
propria). The enrollee is not a candidate for cystectomy and lymph node dissection due to multiple comorbid 
conditions that include diabetes, hypertension, stroke and dementia. The treatment plan is to proceed with 
definitive chemoradiotherapy. IMRT is not medically reasonable and necessary in this case. The National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines) Bladder 
Cancer Version 2.2023 was last updated on April 25, 2023. The NCCN Guidelines do not recommend the use 
of IMRT for bladder cancer.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IMRT for bladder cancer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed tomography, abdomen (74160). 
 
You asked the Plan to pre-approve Computed tomography, abdomen (74160). The Plan denied your request. 
The Plan says the test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when 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 Computed tomography, abdomen 
(74160). Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
presentation and objective information did not reveal an indication for advanced imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Computed tomography, abdomen (74160) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Computed tomography, abdomen (74160).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on October 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are 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 (81455) provided on October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered personal items provided on April 26, 2022, to 
May 1, 2022. 
 
You asked the Plan to pay for non-covered personal items. You say that you disagree with these charges. The 
Plan denied your request. The Plan says the services on this claim have been processed correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-covered personal items have not been met. The copayments for inpatient care and an 
ambulance have been correctly applied. Therefore, we decided that the Plan does not have to pay for non-
covered personal items provided on April 26, 2022, to May 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 13, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that the home health services are not supported in the medical record. Specifically, the claim was not 
billed with a valid type of bill. Home health agencies must submit home health PPS claims with a 4th digit of 
"9". The type of billed on this claim was 0323. 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 December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 7, 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 for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 
June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on July 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as 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. 
 
We find that payment for CPT code 63030 is not supported in the medical record. Specifically, code 63030 was 
billed with modifier -82, indicating that the assistant surgery services were provided by a physician. However, 
the records show that the services were provided by a physician assistant. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the assistant surgery services provided on July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99213 for October 28, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that pre-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99213 was related to and billed on the same day as 
minor surgical procedure billed with code 20610. The records do not support the use of the -25 modifier. 
Payment for code 99213 is included in the global surgical payment for 20610. Therefore, we decided that the 
Plan does not have to pay for the office visit billed with code 99213 for October 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for March 16, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 20610. Payment for code J3490 is included in the global surgical payment for code 
20610. Therefore, we decided that the Plan does not have to pay for the drug services billed with code J3490 
for March 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
April 21, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says the billed codes are 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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 10, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the billed code is an unbundled service. 
 
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 A4239 has a Status Indicator of P on the Physician Fee Schedule. This means that 
no separate payment may be made for procedure code A4239. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4239 billed for date of service March 10, 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 requires inpatient 
rehabilitation level of care. The Plan denied your request. The Plan says the enrollee's care may be provided in 
the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Favorable

 
We decided that the Plan has to pay for the unlisted molecular pathology (81479) provided November 28, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says that this test is deemed not 
medically necessary by the payer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a refractory, metastatic stage IV kidney cancer that has not been previously 
tested with the same test using NGS and has been decided to continue cancer treatment. The NGS test in this 
case came at an appropriate time after trying multiple different agents and enrollee's cancer continued to 
progress. It was ordered and furnished by qualified personnel (the medical oncologist). It met the enrollee's 
medical need and is at least as beneficial as an existing and available medically appropriate alternative which is 
to continue systemic therapy that the enrollee did not respond to. 
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the unlisted molecular pathology (81479) provided November 28, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 26 through 
October 29, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the medical records provided support 
that the inpatient care in dispute was medically justified.  The Plan denied your request. The Plan says the 
enrollee's emergency medical condition was stabilized by October 26, 2022, such that it met the Medicare 
standard for transferability.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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. Our reviewer 
says that the criteria for coverage of OON care have not been met.  Our physician reviewer found all inpatient 
care provided after October 26, 2022, and through October 29, 2022, was not needed on an emergent basis. The 
enrollee was hemodynamically and neurologically stable after the emergency room evaluation. She was stable 
and appropriate for ambulance transport with monitoring to a plan facility for observation/admission level of 
care services. The treating physician did not document (in the physician notes, on a form, or in an order) that 
the patient was not stable for transfer on any dates of service. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on October 26 through October 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
11, 2022. 
 You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim 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 70450 billed for date of service December 11, 
2022.