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

 
We decided that the Plan does not have to pay for codes 88172 and 88173 for date of service May 18, 2023. 
 
You asked the Plan to pay for codes 88172 and 88173. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 3, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for codes 88172 and 88173 have not been met. Therefore, we decided that the Plan does not have to pay for codes 88172 and 88173 for date of service May 
18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 73562 performed on May 18, 
2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they are supported in the record and were billed with modifier -76. The Plan denied your 
request. The Plan says the radiology services are denied because they were billed without an anatomical 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT/HCPCS codes describing services 
performed on anatomic structures that can be distinguished as left or right require laterality modifiers. 
 
We looked at the file and Medicare rules. We have confirmed code 73562, defined as radiologic examination of 
knee; 3 views, was billed without a modifier indicating laterality. Records indicate 73562 was performed on an 
anatomic structure that can be distinguished as left or right. Therefore, a modifier indicating laterality is required. Based on this information, we decided that Medicare rules for coverage of the radiology services have 
not been met. Therefore, we decided that the Plan does not have to pay for the radiology services coded as 
73562 performed on May 18, 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 you need a higher level of care. The Plan denied 
your request. The Plan says your current medical needs do not require IRF services. Care be provided in an 
different setting.  
 
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 your medical, rehabilitation, and nursing needs does not require 
IRF care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely 
provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from this care. The Plan 
denied your request. The Plan says an IRF admission is not required and the enrollee's needs can be safely met 
in other settings.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: Unfavorable

 
We decided that the Plan does not have to pay for the PureWick Female External Catheters. 
 
You asked the Plan to pay for the PureWick Female External Catheters. You say that the items should be 
covered. The Plan denied your request. The Plan says this was purchased through a provider that is not certified 
with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the PureWick Female External 
Catheters.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure (30469). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that the enrollee cannot breathe or sleep 
well at night. The Plan denied your request. The Plan says the clinical value and effectiveness of the VivAer 
procedure in the setting of nasal turbinate hypertrophy 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 pre-approve the VivAer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case, the record indicates that the enrollee has sinusitis and rhinitis in the 
setting of nasal obstruction and alar collapse. There is insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific conditions. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure (30469).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 6, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services were not reported appropriately and are not considered 
medically necessary. The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 1, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 1, 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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found On review of the available records, the enrollee with Debility as described above 
does not meet CMS coverage criteria for IRF admission. 
The enrollee is medically stable as mentioned above and does not need PMR physicians supervision 3 times a 
week in an IRF. 
 No acute rehab nursing needs documented. 
At the current functional mobility level, he needs routine PT and OT, and the enrollee does not need intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. 
 There is no current medical complexity or rehab nursing needs. 
Document does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, 
and nursing needs (combined complexity does not require acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. 
The enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth provided on May 08, 2023. 
 
You asked the Plan to pay for telehealth. You say that it is medically necessary. 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 telehealth provided on 
May 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305, 88312 and 88313) provided on 
October 20, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary and were reported 
appropriately. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that D12.5 has an Excludes1 note in relation to K63.5. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305, 88312 and 88313) provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010 and 99220 rendered on September 3, 
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 the records do not support the services 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 the denied codes is: 
 
CPT 99220: 
 
Initial observation 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 to outpatient hospital "observation status" are of 
high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 93010: 
 
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 99220, the 
documentation does not support either a high complexity level of medical decision-making. There is no 
documentation of the required amount of time. 
 
In terms of CPT 93010, the provided records show a Patient Audit Trail reporting an electrocardiogram (EKG) 
at 16:17 on 9/3/22. Additional records show an EKG report from 9/3/22 showing an interpretation. However, 
the provided records do not clarify that the interpreting physician was a part of the billing group. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93010 and 99220 rendered on September 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 19, 2022, to 
November 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 October 19, 2022, to 
November 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that given the enrollee's multiple acute 
conditions and comorbidities, they are expected to require at least 25 days at an LTACH for continued recovery 
to facilitate a safe discharge to the next appropriate level of care.  The Plan denied your request. The Plan says 
an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not have clinical conditions that cannot be appropriately treated 
in the current hospital, and there are no issues for which a LTACH may offer a therapeutic advantage. The 
enrollee needs can be safely managed in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the enrollee's current condition and 
functional deficits , as well as their multiple comorbidities the enrollee meet the full inpatient acute rehab 
criteria. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is stable and does not require oversight from a rehabilitation 
physician or require skilled rehabilitation nursing. The enrollee needs could be met in 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 the genetic testing provided on June 13, 2023, billed with 
codes 87481, 87798 x12 and 87801 x3. 
 
You asked the Plan to pay for the genetic testing billed. You say that kindly review the attached documents and 
process this claim towards possible payment. 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 
June 13, 2023, billed with codes 87481, 87798 x12 and 87801 x3.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to provide coverage for home health physical therapy services for the enrollee.
You asked the Plan to provide coverage for these services. You say that at the time of the appeal, these services were medically necessary for the enrollee. The Plan denied your request. The Plan says the services are not medically necessary. Maximus overturned the Plans denial for a lack of medical records. The Plan requested a reopen provided additional records.
Our Medical Director looked at the reopen request and the case file. At issue is coverage for home Physical Therapy (PT). The enrollee was a then 84-year-old man with a medical history that included chronic lower extremity venous stasis with severe lymphedema, chronic sacral ulcer, chronic kidney disease, and obesity. The enrollee is wheelchair-bound. It is noted that PT was discharged with no further visit, per patient request. The enrollee states that he would be working with a lymphedema therapist and did not have the strength or energy for participate in anything further. Based on the limited medical records available, the documentation does not do not support that home therapy is required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to provide coverage for home health physical therapy services for the enrollee.