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 has lost a significant amount of strength 
and mobility and it is very difficult to maintain non-weightbearing status due to body habitus. The enrollee 
would benefit from intense rehabilitation to regain strength and prior level of mobility and independence. The 
Plan denied your request. The Plan says the enrollee's records do not show rehabilitation needs are complex. 
The Plan says that the services needed may be provided safely in a lower level of care.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 the enrollee requires continued monitoring that is 
given at an inpatient rehabilitation hospital. The Plan denied your request. The Plan says an IRF admission 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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on June 29, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for physical therapy. You say that the out-of-network services were medically 
necessary. The Plan denied your request. The Plan says the physical therapy should have been provided by an 
in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physical therapy 
provided on June 29, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 30, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 17, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81351, 81194, 
81121, 81272, 81210, 81275, 81276, 81235, 81315, 81310, 81120, 81245, and 81270 for date of service April 
18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
1 code must be submitted for the panel. 
 
 We looked at the file and Medicare rules. Review of the file shows that this was a panel that was not billed with 
a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with codes 81351, 81194, 81121, 81272, 81210, 81275, 81276, 81235, 81315, 81310, 
81120, 81245, and 81270 for date of service April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on March 11, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that diagnosis code J44.9 is valid for oxygen. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J44.9 has an Excludes1 note in relation to J43.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for 
oxygen equipment provided on March 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4245 billed for date of service June 9, 
2023.  
 
You asked the Plan to pay for procedure code A4245. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code A4245 is 0. The MAI value for this code is 3. You billed 1 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4245 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4245 billed for date of service June 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service December 
24, 2022. 
 
You asked the Plan to pay for procedure code S9083. You say that you have a contract with the Plan that has an 
allowed amount for this code. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  The Plan also says that the contract you reference in your appeal applies only to the Plan's 
commercial products.  This member is enrolled in a Medicare Advantage product, so Medicare coding rules 
apply. 
 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 S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service December 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480, 80307) provided on May 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 the lab services have been met. No 
clinical or lab documentation was provided to support the billed custom panel. The plan requested additional 
information and none was provided. Therefore, we decided that the Plan does not have to pay for lab services 
(G0480, 80307) provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic metabolic panel (80048) and complete blood count 
(85025) provided on May 15, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that the lab must see all patients that need care. 
The provider has no option to determine which patient they want to perform services on. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the basic metabolic panel (80048) and complete 
blood count (85025) provided on May 15, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on April 11, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing this denial. The Plan denied your 
request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that G89 has an Excludes1 note in relation to R52. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
testing provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on May 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have never been charged for these services. 
The Plan denied your request. The Plan says that code 99386 is not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on May 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on June 9, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on June 9, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 
87500.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Vertiflex Superion spacer 
is considered experimental in nature. More research is needed to support its use. The services are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve physical therapy. You say that the out of network physical therapy should 
be covered due to how close it is to your residence. The Plan denied your request. The Plan says the physical 
therapy should be covered by network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on November 28, 2022. 
 
You asked the Plan to pay for the lab panel. 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 if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab panel provided on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 23, 2023, billed with 
codes 81432 and 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 23, 2023, billed with codes 81432 and 81433.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power option. You say that the 
enrollee has been in a power wheelchair for over eight years. You say that the enrollee's current chair is over 
six years old. You also say that the enrollee requires this power wheelchair to complete their MRADLs. The 
Plan denied your request. The Plan says the enrollee's condition does not significantly impair their ability to 
participate in mobility related activities of daily living (MRADLs). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 a Group 3 power wheelchair with 
multiple power option. Our reviewer says that the request for a Group 3 power wheelchair with multiple power 
option is not medically necessary. Our physician reviewer found the provided documentation indicates that the 
enrollee is able to perform mobility related activities of daily living (MRADLs) in the home. Therefore, the 
reviewer found that the request for a Group 3 power wheelchair with multiple power options is not medically 
reasonable or 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 a Group 3 power wheelchair with multiple power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options and accessories.