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

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee requires the level of observation and treatment provided in terms of 
physician oversight and skilled nursing care. The enrollee required a trans metatarsal amputation on the right 
side on July 25, 2023. The enrollee currently requires a wound vacuum as well as intravenous (IV) vancomycin 
and oral metronidazole. The enrollee requires complex wound management and administration of IV 
antibiotics. The enrollee has also had a decline in the enrollee's level of function and mobility and would 
benefit from skilled therapy services, including physical and occupational therapies. Therefore, the skilled 
nursing facility admission is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 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 urinary tract infection (UTI) panel coded as 87481, 
87500, 87640, 87652, 87798, 87899, 87900 provided December 1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you disagree with this decision and have 
supplied additional documents for review.  The Plan denied your request. The Plan says the documentation 
does not support that the services rendered were 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support LCD criteria for MolDX: Molecular Syndromic 
Panels for Infectious Disease Pathogen Identification Testing L38988. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the urinary tract infection (UTI) panel coded as 87481, 87500, 87640, 87652, 87798, 
87899, 87900 provided December 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroplasty and/or transposition; cranial nerve and 
ligation or biopsy, temporal artery surgery. 
 
You asked the Plan to pre-approve neuroplasty and/or transposition; cranial nerve and ligation or biopsy, 
temporal artery surgery. You say that neuroplasty and/or transposition; cranial nerve and ligation or biopsy, 
temporal artery surgery is medically necessary. The Plan denied your request. The Plan says neuroplasty and/or 
transposition; cranial nerve and ligation or biopsy, temporal artery migraine surgery is still a procedure under 
development needing further clinical trials. As such, this procedure is experimental/investigational. Given the 
lack of quality evidence from well-designed trials and the need for further research, this procedure is not 
medically reasonable or 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 neuroplasty and/or transposition; 
cranial nerve and ligation or biopsy, temporal artery surgery. Our reviewer says that the requested neuroplasty 
and/or transposition; cranial nerve and ligation or biopsy, temporal artery surgery is not considered medically 
reasonable and necessary. Our physician reviewer found that you have a diagnosis of chronic migraine without 
aura, intractable, without status migrainosus. You were having headaches of mild to moderate severity 20 days 
per month. Multiple medications had been tried. On January 24, 2023, you underwent right greater occipital 
nerve neurolysis, right third occipital nerve neurolysis transection and implantation into muscle, right lesser 
occipital nerve neurolysis, and ligation of the right occipital artery. There is insufficient support in the medical 
literature for neuroplasty and/or transposition of a cranial nerve and ligation of the temporal artery for patients 
with chronic migraine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuroplasty and/or transposition; cranial nerve and ligation or biopsy, temporal 
artery surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve neuroplasty 
and/or transposition; cranial nerve and ligation or biopsy, temporal artery surgery.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) G0483 and 80307. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 81002.  
 
You asked the Plan to pay for drug testing services (80307, G0483 and 81002) billed for date of service 
September 30, 2022. You say that these services were reported correctly. The Plan says that the payment for 
code 81002 is included in the payment for code 80307. 
 
We decided that the Plan has to pay for the services described by procedure code(s) G0483 and 80307.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) G0483 and 80307.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81002. 
 
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 81002 
is a column II code to column I code 80307. 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 the services described by procedure code(s) 81002. 
 
 
 
 
 
 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 pay for procedure codes 96365, 96366, and G0108 billed for 
December 29, 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 codes 96365, 96366, and G0108 are 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code G0108 is diabetes outpatient self-
management training services, individual, per 30 minutes.  
We find that CPT codes 96365, 96366, and G0108 are not supported in the medical record. Specifically, the 
records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate code for these services. 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 codes 
96365, 96366, and G0108 billed for December 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (99291 and 99292) provided on December 
26, 2022. 
 
You asked the Plan to pay for hospital services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim was submitted with two 
incompatible diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition together with the condition with the note.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital services have not been met. Specifically, codes within the R06 code set have an Excludes1 
note with codes within the R96 code set. This claim was submitted with diagnosis codes J96.22, R06.03, and 
R06.02, which generally should not be reported together. Therefore, we decided that the Plan does not have to 
pay for hospital services (99291 and 99292) provided on December 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on April 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the podiatry services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says these services are not covered when received out-of-
network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says 
that the enrollee may use either network providers or out-of-network providers for certain services. The Plan 
contract also says that out-of-network podiatry services are not covered. 
 
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 podiatry services provided on April 5, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 49418 and 99152. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 99153.  
 
You asked the Plan to pay for practitioner services provided on March 30, 2023, billed with procedure codes 
99153, 49418, and 99152. You say that the claim is billed correctly and should be paid. The Plan says that the 
place of service is inappropriate for the procedure 
 
We decided that the Plan has to pay for the services described by procedure code(s) 49418 and 99152.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 49418 and 99152.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE 
only code and that PE are not payable to the physician for services provided in the facility setting.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99153 have not been met. There is no separate 
payment to the physician for code 99153 when performed in the facility setting. Therefore, we decided that the 
Plan does not have to pay for the services described by procedure code(s) 99153. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; 
placement of adjustable gastric restrictive device (43770).  
 
You asked the Plan to pre-approve a laproscopic sleeve gastrectomy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria.  
 
The Plan follows Medicare rules. Medicare rules say that laproscopic sleeve gastrectomy is covered when you 
meet the definition of morbid obesity which is defined as a body mass index (BMI) is greater than 35 and comorbid conditions exist. 
 
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 laproscopic sleeve gastrectomy. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that you do not meet 
Centers for Medicare and Medicaid Services (CMS) criteria for a body mass index (BM)I that is greater than 
35 kg/m2. Your BMI has ranged from 32-34 kg/m2. 
 
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 laproscopic sleeve gastrectomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; placement of 
adjustable gastric restrictive device (43770).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on January 16, 2023. 
 
You asked the Plan to pay for a mental health visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a mental health visit 
provided on January 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on March 
9, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that these services were medically necessary and 
are supported in the medical record. The Plan denied your request. The Plan says this code is not supported in 
the medical record. 
 
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 99308 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using total time on the date of the encounter for code 
selection, 15 minutes must be met or exceeded. We find that CPT code 99308 is not supported in the medical record. Specifically, the documentation supports 
that this care was provided in an assisted living facility rather than a nursing facility. Based on this information, 
we decided that Medicare rules for coverage of nursing facility care have not been met. Therefore, we decided 
that the Plan does not have to pay for subsequent nursing facility care (99308) provided on March 9, 2023.
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 services are medically necessary for continued 
medical and pain management with physical and occupational therapy to help the enrollee return to baseline.  
The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BioFire FilmArray Respiratory Panel (0202U) provided 
November 16, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you rendered medically necessary services to 
the enrollee. Standards of good faith and fair dealing require the Plan process the claim submitted and remit 
payment for the services rendered. The Plan denied your request. The Plan says the request for the BioFire 
FilmArray Respiratory Panel is 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support LCD criteria and thus BioFire FilmArray 
Respiratory panel was not 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for BioFire FilmArray Respiratory Panel (0202U) provided November 16, 2022.