Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 28, 2022, to 
February 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 28, 2022, to 
February 10, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for a lumbar compression fracture. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 1, 2022, to 
March 2, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA. 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 February 1, 2022. The NOA was not received by the Plan until May 2, 
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 February 1, 2022, to March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99220) provided on October 16, 2022. 
 
You asked the Plan to pay for the observation care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation did not support the billed services. 
 
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 99220 is initial observation care, for the evaluation and 
management of a patient, requiring a comprehensive history; a comprehensive examination; and medical 
decision making of high complexity. 
 
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 the observation care. Our reviewer says that the records do 
not support the code billed. Our reviewer found the documentation did not sufficiently support a comprehensive history or physical, and did not support decision-making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the observation care have not been met. Therefore, we decided that the Plan 
does not have to pay for observation care (99220) provided on October 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 for date of service December 15, 
2022. 
 
You asked the Plan to pay for procedure code 87086. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87086 is culture, bacterial; quantitative colony count, 
urine.  
We find that CPT code 87086 is not supported in the medical record. Specifically, this code was billed with 
diagnosis R97.20 (elevated prostate specific antigen). This diagnosis is not listed as a covered diagnosis for 
code 87086. Since code 87086 was not billed with a covered diagnosis, the claim is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of procedure code 87086 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 87086 for date of service 
December 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PainTEQ LinQ procedure (0775T). 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee has not improved with conservative 
therapy. You state that the procedure is medically necessary and benefit the enrollee that the enrollee undergoes 
a minimally invasive left sacroiliac (SI) joint fusion using the posterior approach.  The Plan denied your 
request. The Plan says medical studies have not proven this service is helpful for the treatment of health 
problems.  
 
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 the surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested PainTEQ LinQ procedure, in this case, is not medically reasonable or necessary.  detailed documentation is not evident regarding imaging or radiographic evidence supporting a sacroiliitis 
pathology. Multiple other plausible pain generators including at the lumbosacral spine are evident. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested PainTEQ LinQ procedure, in this 
case, is not medically reasonable or necessary (and is also considered experimental.) 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the PainTEQ LinQ procedure (0775T).
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 you are requesting reconsideration of a SNF 
admission. The Plan denied your request. The Plan says the 100-day benefit was exhausted on June 2, 2023 and 
effective June 3, 2023, the continued SNF stay would not be covered. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from January 10, 2023 to 
June 2, 2023. The Plan has covered 100 days of SNF care. 
 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. 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 procedure code 99292 billed for September 22, 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 procedure code 99292 is not supported. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of 
an additional 30 minutes of critical care time spent with the enrollee. 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 procedure code 99292 billed for September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on November 
18, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
November 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical assessment 
provided on February 8, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical assessment. The Plan denied 
your request. The Plan says there is no coverage for out-of-network telehealth services.  
 
The Plan contract says there is no coverage for out-of-network telehealth services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychiatric diagnostic evaluation with medical assessment  have not been met. Therefore, we 
decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical assessment 
provided on February 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided 
from February 20, 2023, to February 22, 2023. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you were 
admitted to observation care and the copayment for the emergency room services should be waived because 
you were admitted within 24 hours. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for emergency care.  
 
 You have been asked to pay a $110 copayment for the emergency department visit. This service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency department 
visit provided from February 20, 2023, to February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from September 15, 
2021, to September 22, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have correctly billed the services at issue. The Plan denied your request. The Plan says the principal diagnosis 
code is not supported in the medical records. 
 
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 provided with principal diagnosis code A41.51, defined as Sepsis 
due to Escherichia coli. 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 the inpatient hospital services at issue do 
not meet criteria for payment at the DRG originally billed. Our physician reviewer found that there is no 
clinical or laboratory evidence of sepsis in the provided records. The review has determined that the 
documentation does not support diagnosis code A41.51.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from September 15, 2021, to September 22, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies (A9276) for a CGM. 
 
You asked the Plan to pre-approve CGM supplies. You say that the requested items are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that codes A9276 and A9277 describe the supplies 
used with a CGM that does not meet the definition of DME. Based on this information, we decided that 
Medicare rules for coverage of CGM supplies coded A9276 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve supplies (A9276) for a CGM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group3 power wheelchair (PWC) (K0862) and 
accessories. 
 
You asked the Plan to pre-approve a group 3 PWC and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says you do not have a medical diagnosis of neurological 
disease, myopathy or congenital skeletal deformity causing mobility limitation for which a Group 3 power 
wheelchair base would be medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group3 
power wheelchair (PWC) (K0862) and accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need to see this 
doctor. The Plan denied your request. The Plan says the requested trip exceeds your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation within a 50-mile limit. 
 
We looked at your request, the records in the case file, and the rules. The requested trip is greater than 50 miles 
of driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the brain. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says that an MRI of the 
brain is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the brain. Our reviewer says 
that an MRI of the brain is medically necessary. Our physician reviewer found that the enrollee has no 
documented hearing loss, and the concern is for brain stem and cerebellar pathology. Without hearing loss 
acoustic neuroma is highly unlikely and due to their symptoms brain stem and cerebellar pathology need to be 
ruled out. Therefore, the requested MRI of the brain without and with contrast is appropriate and should be 
approved. 
 
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 MRI of the brain have not been met. Therefore, we decided that the Plan has 
to pre-approve an MRI of the brain.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 portable ventilator (E0466). 
 
You asked the Plan to pre-approve a Life2000 ventilator. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000 ventilator. Our reviewer 
says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the provided records in this case do not document a diagnosis of neuromuscular disease, thoracic 
restrictive disease, or chronic respiratory failure consequent to COPD. 
 
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 Life2000 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Life2000 portable ventilator (E0466).