Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs more skilled nursing days in the 
current facility. The Plan denied your request. The Plan says the enrollee has no daily skilled nurse or therapist 
needs. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on November 29, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that anesthesia charges performed in a hospital 
setting are covered. The Plan denied your request. The Plan says you billed an incorrect POS code on this 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill with an appropriate Place of 
Service (POS) code to indicate where the service took place. POS code 21 should be used for services in an 
inpatient hospital setting. POS code 22 should be used for services in an outpatient hospital setting. In this case, 
you billed the services in dispute with POS code 22 (outpatient hospital).  However, the patient was in an 
inpatient stay on the date of service in question.  As a result, POS 21 should have been billed instead. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99497 provided on July 7, 2022. 
 
You asked the Plan to pay for procedure codes 99223 and 99497. You say that the medical records support the 
billing of codes 99223 and 99497. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 99223 and 99497. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. The definition of code 99497 is Advance care planning including the explanation and discussion of 
advance directives such as standard forms (with completion of such forms, when performed), by the physician 
or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), 
and/or surrogate. 
 
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 procedure codes 99223 and 99497. Our reviewer says that 
the medical records do not support the billing of codes 99223 and 99497. Our reviewer found for code 99223, 
provided records in this case do not document a chief complaint, an extended history of present illness, a 
review of all additional body systems and a complete past, family, and social history. Provided records in this 
case do not document a general multi-system examination or a complete examination of a single organ system. 
Provided records in this case do not document 2 out of 3 of an extensive number of diagnoses or management 
options, an extensive amount and complexity of data reviewed and high risk of complication. 
 
For code 99497, provided records in this case do not document an explanation and discussion of advance 
directives such as standard forms (with completion of such forms, when performed), by the physician or other 
qualified health care professional. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99223 and 99497 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99497 provided on July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (93228, 93229). 
 
You asked the Plan to pre-approve an external mobile cardiovascular telemetry. You say that you disagree with 
the denial. The Plan denied your request. The Plan says the request is not medically necessary because the 
records do not show that, and a 24-hour ambulatory ECG has been performed and do not provide a reason why 
a 24-hour ambulatory ECG would be unlikely to capture and record the dysrhythmia. 
 
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 an external mobile cardiovascular 
telemetry. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found at issue is whether the requested authorization for an 
MCOT monitor was appropriate and medically necessary. The enrollee has a history of palpitations and 
documented atrial fibrillation. As such, guidelines would not support a need for MCOT monitoring in this 
setting. In summary, there was insufficient documentation to support the medical necessity for an MCOT 
monitor in this enrollee's clinical management. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external mobile cardiovascular telemetry have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (93228, 93229).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608). 
 
You asked the Plan to pre-approve Brain imaging, positron emission tomography (PET); metabolic evaluation 
(78608). The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 Brain imaging, positron emission 
tomography (PET); metabolic evaluation (78608). Our reviewer says that the service is not medically 
necessary. Our physician reviewer found requested exam does not fulfill CMS criteria for approval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Brain imaging, positron emission tomography (PET); metabolic evaluation (78608) have not been met. Therefore, we decided that the Plan does not have to pre-approve Brain imaging, 
positron emission tomography (PET); metabolic evaluation (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93460 and 99152 billed for date of service January 28, 
2022. 
 
You asked the Plan to pay for codes 93460 and 99152. You say that You did not provide a specific argument 
with your appeal request. The Plan denied your request. The Plan says you did not provide sufficient medical 
records to support payment. 
 
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 codes 93460 and 99152 have been met. 
Specifically, you did not provide any medical records for the date of service billed.  You only provided medical 
records with dates of January 26, 2022, and January 27, 2022. Without records from the actual date of service 
billed, we cannot determine if the services were supported and billed correctly. Therefore, we decided that the 
Plan does not have to pay for codes 93460 and 99152 billed for date of service January 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computerized corneal topography, unilateral or bilateral, with 
interpretation and report rendered on December 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of irregular astigmatism. The enrollee does not have any conditions that 
would make this service medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for computerized corneal topography, unilateral or bilateral, with interpretation and report rendered 
on December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services provided on November 1, 2022, 
and billed with procedure codes 87481, 87500, 87641, 87651, 87653 and 87798. 
 
You asked the Plan to pay for laboratory testing services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single procedure code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory testing services have not been met. Specifically, the services at issue were reported with 
multiple codes. Therefore, we decided that the Plan does not have to pay for laboratory testing services provided on November 1, 2022, and billed with procedure codes 87481, 87500, 87641, 87651, 87653 and 
87798.
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 medical conditions require daily 
monitoring/adjusting by a medical physician. The Plan denied your request. The Plan says the enrollee's current 
medical status does not require intensive physician and nursing oversight that can only be provided on an 
inpatient rehabilitation unit. 
 
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 January 9, 2022, to 
February 7, 2022. 
 You asked the Plan to pay for the home health services. You say that all of the codes billed are valid, so this 
claim should be paid. 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 9, 2022. The NOA was not received by the Plan until July 7, 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 9, 2022, to February 7, 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 member has trouble walking and needs physical 
therapy before being released home. The Plan denied your request. The Plan says the member does not meet all 
the requirements for an IRF admission. 
 
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 member's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this member will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The 
member can receive further services at a lower 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is 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 provided on August 25, 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 member is becoming weaker by the day and 
requires rehabilitation. The Plan denied your request. The Plan says the member does not meet the 
requirements for an IRF admission. 
 
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 
does not require treatment by multiple therapies or an intensive rehabilitation therapy program. While the 
medical record supports a need for skilled therapy, there is no documented need for intensive rehabilitation 
services. The member can receive further services at a lower 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic arterial embolization (37243, 37244). 
 
You asked the Plan to pre-approve prostatic arterial embolization. You say that prostatic arterial embolization 
is a medical necessity for you. The Plan denied your request. The Plan says prostatic arterial embolization is 
experimental/investigational. 
 
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 prostatic arterial embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that prostatic arterial embolization is considered an experimental technique to 
treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-
term safety and efficacy. However, the most recent guidelines do not recommend this procedure outside of a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding radiation 
exposure, postembolization syndrome, vascular access, technical feasibility and higher clinical failure rate 
compared with more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostatic arterial embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve prostatic arterial embolization (37243, 37244).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0480, 80307) provided on September 8, 
2021. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this claim was not 
filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the drug testing was not filed until October 24, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the drug testing (G0480, 80307) provided on September 8, 2021.