Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on April 8, 2022.  
 
You asked the Plan to pay for the office visit. You say that this claim should be paid.  The Plan denied your 
request. The Plan says that an appeal review was not performed as the time frame was missed. 
 
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. This claim was denied stating that the charge was incidental to another service. 
However, no evidence was provided showing another service to which this service was incident. Without this 
evidence, we find that the denial of payment is not substantiated.  Therefore, we decided that the Plan has to 
pay for the office visit provided on April 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310) and cone beam computed 
tomography (CT) image capture with field of view of both jaws (D0383). 
 
You asked the Plan to pre-approve a consultation and cone beam CT image capture with field of view of both 
jaws. You say that the services are necessary. The Plan denied your request. The Plan says the requested 
services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.    Therefore, we decided that the Plan does not have to pre-approve a 
consultation (D9310) and cone beam computed tomography (CT) image capture with field of view of both jaws 
(D0383).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service December 
20, 2022. 
 You asked the Plan to pay for procedure code 81345. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service December 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from September 28, 2022, to 
September 29, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the claim must include modifier GN, GO, or GP, 
to distinguish the discipline of the plan of care under which the service is delivered. 
 
We looked at the file and Medicare rules. In this case, code 97163 was not billed with the GP modifier as 
required by Medicare rules. As such, the entire claim has been denied. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the services provided from September 28, 2022, to September 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on March 
31, 2022, billed with code IEIE1.  
 
You asked the Plan to pay for the SNF care as billed. You say that this claim was coded correctly. The Plan 
denied your request. The Plan says the functional level was not correctly documented which means that the 
billing code is not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that payment for SNF services is based on a HIPPS 
code with five case-mix groups which are assigned based on the information from the MDS assessment. The 
rules say that for reporting functional abilities in Section GG, facilities must assess self-care performance based 
on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or 
family documented in the residents medical record during the three-day assessment period. It is expected that 
an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day 
assessment period. 
 
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 SNF care as billed. Our reviewer says 
that the billed code is not supported.  Our physician reviewer found the provided medical records do not 
document that the enrollee was utilizing a mechanically altered diet in the look back period of 04/01/2022-
04/07/2022. The records do not support the section GG item coding.  
 
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 SNF care as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) services provided on March 31, 2022, billed with 
code IEIE1.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on April 25, 2022, billed with 
code 93000. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 93000 is Electrocardiogram, routine ECG with at least 12 
leads; with interpretation and report. 
 
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 imaging services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found the medical record does not include an 
electrocardiogram interpretation and report and therefore cannot be verified.  
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on April 25, 2022, billed with code 93000.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 28, 2022, billed 
with codes 81226, 81306, 81225, 81335, 81328, 81231, 81227, 81232, 81241, 81291, 81240 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue have been billed 
correctly. 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 
November 28, 2022, billed with codes 81226, 81306, 81225, 81335, 81328, 81231, 81227, 81232, 81241, 
81291, 81240 and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this device is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 home ventilator. Our reviewer says 
that the requested equipment is not medically necessary. Our physician reviewer found the records show that the treatment being provided could be provided with a BiPAP machine. A ventilator is not medically necessary 
in this case. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS3D testing (898361, 88312, 88305, 88112) 
provided on October 3, 2022.  
 
You asked the Plan to pay for the WATS3D testing. You say that this testing is recommended in the standard 
of practice guideline of major medical studies. The Plan denied your request. The Plan says the clinical value 
and effectiveness of WATS3D testing for screening, diagnosis or surveillance of cancerous or pre-cancerous 
esophageal lesions have not been demonstrated in the peer-reviewed literature.  
 
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 WATS3D testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found that the American Society for Gastrointestinal Endoscopy has made a conditional 
recommendation based on low quality evidence and suggests using WATS-3D in addition to white light 
endoscopy in patients with known or suspected Barrett's esophagus. The case file does not contain 
documentation that the enrollee in this case has known or suspected Barrett's esophagus.  
 
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 WATS3D testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS3D testing (898361, 88312, 88305, 88112) provided on October 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on dates of service from 
October 16, 2021, to November 14, 2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment for home health services have not 
been met. 
 The Plan must follow Medicare rules. Medicare rules say that the following case mix variables are obtained 
from home health or other Medicare claims: admission source, timing and clinical group. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the services at issue have been reported with 
an indicator of an institutional admission source. The case record does not support that the enrollee was 
institutional (that is, at an inpatient facility) prior to the commencement of home health services. Therefore, we 
decided that the Plan does not have to pay for home health services provided on dates of service from October 
16, 2021, to November 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial 
denture. 
 
You asked the Plan to pre-approve the dental services. You say that you can hardly eat, and your provider is 
recommending these services. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 01, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial 
denture.
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 would benefit tremendously from 
intensive rehabilitation. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation care. There is not a reasonable expectation that the 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. You say that IDPN is needed to prevent further nutritional decline. 
The Plan denied your request. The Plan says that there is no documentation indicating that enteral nutrition has 
been considered and ruled out or tried and failed. 
 
The Plan follows Medicare rules. Medicare rules state that parenteral nutrition such as IDPN is 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 IDPN. Our reviewer says that the 
enrollee meets criteria for IDPN. Our physician reviewer found IDPN is indicated for the enrollee on several 
levels. The enrollee has severe malnutrition. There is enteral dysfunction with diarrhea that impairs absorption 
of nutrients. There is presence of wounds that require more than adequate nutrition for healing. There is a very 
poor outcome associated with the enrollee's albumin of 2.5. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have been met. Therefore, we decided that the Plan has to pre-approve 
intradialytic parenteral nutrition (IDPN).  
 
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 services rendered from May 5, 2022, to June 
3, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the 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 May 5, 2022. The NOA was not received by the Plan until June 13, 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 the home health services rendered from 
May 5, 2022, to June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the Medicare guidelines say home 
NIVs are not reasonable and necessary when the sole purpose of the home NIV is to function as a respiratory 
assist device. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD, obstructive sleep apnea untreated, obesity hypoventilation syndrome, pulmonary hypertension, and 
HFpEF. The enrollee was recently hospitalized with pneumonia and acute exacerbation of COPD, requiring 
intubation. ABGs when acutely ill were consistent with acute on chronic hypercarbic respiratory failure. There 
are no pulmonary function tests to confirm airways obstruction and assess severity. There is no ABG done 
while stable to document chronic CO2 retention. If that is present, the enrollee may benefit from BiPAP with 
AVAPS during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can 
be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, lumbar, or sacral (caudal); with imaging 
guidance (62323). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show the enrollee does not have four weeks of conservative care or radiologic imaging evidence of 
radiculopathy. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee has a history of chronic low back pain due to spondylolisthesis and radiculopathy. 
The record sent by the provider indicates that she was evaluated on February 24, 2023, for back pain without 
radiation. She was noted to have pain with lumbar range of motion, lumbar paraspinal muscle tenderness, 
positive straight leg raise, and tingling of the lower extremities. She has been treated with medications, ice, and 
heat. An MRI of the lumbar spine and physical therapy were ordered. In this case, the enrollee has not 
completed four weeks of non-invasive conservative therapy and radiological image-based diagnostic testing 
has not been completed. The review has determined that the enrollee does not meet criteria for approval of the 
requested injection. The injections are 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, 
steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar, or sacral (caudal); with imaging guidance (62323).