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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services to regain 
maximum function. 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 the enrollees 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus liquid biopsy (81455) provided January 21, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of this 
determination and coverage of the Tempus liquid biopsy CGP panel test at the in-network benefit level. The 
Plan denied your request. The Plan says the requested test is not reasonable and necessary because Tempus xF 
has not had FDA approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus liquid biopsy (81455) provided January 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the continuous intraoperative neurophysiology monitoring (G0453) 
provided on November 8, 2022. 
 
You asked the Plan to pay for the IONM service. You say that this was medically necessary for the enrollee. 
The Plan denied your request. The Plan says that this service is considered experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not request medical records to support that this service 
is not medically necessary. Without medical records, it cannot be determined if this service is experimental in 
the enrollees clinical situation. Therefore, we decided that the Plan has to pay for the continuous intraoperative 
neurophysiology monitoring (G0453) provided on November 8, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on February 2, 
2023. 
 
You asked the Plan to pay for emergency room services. You say that you are requesting reconsideration for 
services advising the claim was coded correctly. The Plan denied your request. The Plan says the claim was not 
filed with a valid diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must comply with ICD-10-CM Coding 
guidelines. The guidelines state that a manifestation code is not appropriate as a primary diagnosis as the 
etiology should be sequenced first. 
 We looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of emergency room services have not been met. Specifically, this claim was billed with 
primary diagnosis code M01.X22.  Diagnosis code M01.X22 has a "code first" note in the ICD-10 Manual. 
This means that it cannot be used as a primary diagnosis. Therefore, we decided that the Plan does not have to 
pay for emergency room services (99285) provided on February 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided January 15, 2023, to 
February 13, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's 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 January 15, 2023. The NOA was not received by the Plan until March 1, 
2023. 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 the home health services 
provided January 15, 2023, to February 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot be safely discharged home and require 
SNF services to regain your prior level of functioning. The Plan denied your request. The Plan says the request 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have 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 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 a continuation of SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81518 billed for date of service March 23, 2023. 
 
You asked the Plan to pay for code 81518. You say that this testing was medically necessary to determine the 
length of endocrine therapy needed. The Plan denied your request. The Plan says the billing of code 81518 is 
not supported by the medical records. The records do not contain sufficient detail to support the billed charges 
because the documentation does not clearly identify the genes tested. 
 
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 81518 is Oncology (breast), mRNA, gene expression 
profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-
embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit 
from extended endocrine therapy. 
 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 code 81518. Our reviewer says that code 81518 is not 
supported by the medical records. Our reviewer found the medical records included do not indicate specifically 
the documentation requirements to be able to bill procedure code 81518. The documentation needed to support 
this code should include: Disease type, material analyzed, number of markers, methodology, number of 
functional domains, specimen type, algorithm, and report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 81518 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 81518 billed for date of service March 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by an out-of-
network provider on April 4, 2023. 
 
You asked the Plan to pay for outpatient mental health services. You say that your previous plan did not require 
prior authorization The Plan denied your request. The Plan says this service requires authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may offer a Point of Service (POS) option 
and may either require or waive prior authorization rules for obtaining POS services. The Plan contract states 
that prior authorization is required for out-of-network outpatient mental health care. 
 
We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, 
we decided that Medicare rules for coverage of outpatient mental health services have not been met. Therefore, 
we decided that the Plan does not have to pay for outpatient mental health services provided by an out-of-
network provider on April 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy x-ray absorptiometry (DXA), bone density 
study, provided on December 16, 2022, billed with procedure code 77080. 
 
You asked the Plan to pay for radiology services. You say that you are requesting reconsideration for services. 
The Plan denied your request. The Plan says this service is not covered when considered preventative. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors will pay claims for screening tests 
when the claim contains CPT procedure code 77080 and contains a valid diagnosis code indicating the reason 
for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiology services have not been met. This claim was billed with diagnosis code Z13.820. The 
claim has not been billed with a diagnosis code that indicates the reason for the test is postmenopausal female, 
vertebral fracture, hyperparathyroidism, or steroid therapy. Therefore, we decided that the Plan does not have 
to pay for a dual-energy x-ray absorptiometry (DXA), bone density study, provided on December 16, 2022, 
billed with procedure code 77080.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from December 30, 2021, to 
January 1, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
secondary diagnosis code should remain on the claim and the claim should be processed for payment as 
originally billed. The Plan denied your request. The Plan says that diagnosis code J96.01 is not supported, 
which resulted in a DRG change. 
 
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 with diagnosis code J96.01, defined as acute respiratory failure 
with hypoxia. 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 diagnosis code J96.01 is justified. Our physician 
reviewer found that the enrollee presented with a fever, shortness of breath and hypoxia. The enrollee was 
documented to have acute respiratory failure with hypoxia requiring oxygen from COVID-19. 
 
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 from December 30, 2021, to January 1, 2022, at the 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service September 
22, 2022, to October 21, 2022. You asked the Plan to pay for the billed services. You say that the final claim should be processed regardless of 
an untimely NOA. The Plan denied your request. The Plan says the NOA was not received timely.  
 
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 September 22, 2022. The NOA was not received by the Plan until February 
17, 2023. 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 the home health care billed for 
dates of service September 22, 2022, to October 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 14, 
2023, to February 10, 2023. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements 
for approval. 
 
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 pay for 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 the enrollee did require skilled nursing or skilled therapy services that require the 
specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. However, the enrollee 
did not require skilled services on a daily basis. The enrollee also did not require skilled services on an 
inpatient basis in a 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 pay for skilled nursing facility (SNF) care provided from January 14, 2023, to February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for laser treatment for facial rosacea and sunscreen 
provided on December 22, 2022. 
 
You asked the Plan to reimburse you for laser treatment for facial rosacea and sunscreen. You say that you had 
to change to a new dermatologist because the laser equipment from the first doctor's office had malfunctioned 
and would not be operable for several months. The Plan denied your request. The Plan says the services are not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of laser treatment for facial rosacea and 
sunscreen have been met. No medical records were provided. Therefore, we decided that the Plan does not 
have to reimburse you for laser treatment for facial rosacea and sunscreen provided on December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from continued skilled 
occupational therapy services to address deficits and increase your independence in basic activities of daily 
living and functional mobility prior to discharge. The Plan denied your request. The Plan says admission to an 
IRF 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 the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Ottobock Kenevo MPK and Ottobock Maverick Comfort. 
 
You asked the Plan to pre-approve the Ottobock Kenevo MPK and Ottobock Maverick Comfort.. You say that 
the items are medically necessary. The Plan denied your request. The Plan says that the items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that overage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Ottobock Kenevo MPK and 
Ottobock Maverick Comfort.. Our reviewer says that the items are medically necessary. Our physician 
reviewer found the physician notes indicate the enrollee has K3 functional level potential and has specific 
needs for the requested components, 
 
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 Ottobock Kenevo MPK and Ottobock Maverick Comfort. have been met. 
Therefore, we decided that the Plan has to pre-approve the Ottobock Kenevo MPK and Ottobock Maverick 
Comfort.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for F2 and F5 gene analysis (81240, 81241) provided on 
February 1, 2023. 
 
You asked the Plan to pay for genetic testing. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under 
81240 and 81241 are unlikely to impact therapeutic decision-making in the clinical management of the patient 
and will be denied automatically as not medically necessary: 
 
We looked at the file and Medicare rules. The codes at issue are not covered. Based on this information, we 
decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for F2 and F5 gene analysis (81240, 81241) provided on February 1, 2023.