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

 
We decided that the Plan has to pay for the services described by procedure codes 43249, 45378, 43239, and 
G0500. We decided that the Plan does not have to pay for the services described by procedure code 99153.  
 
You asked the Plan to pay for to pay for procedure codes 99153, 43249, 45378, 43239, and G0500 billed for 
date of service May 10, 2023. You say that medical records were provided. The Plan says that the rules for 
payment have not been met. 
 
We decided that the Plan has to pay for the services described by procedure codes 43249, 45378, 43239, 
and G0500.  
 
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 codes 43249, 45378, 43239, and 
G0500 billed for date of service May 10, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99153. 
 
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 find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Based on this information, we decided 
that Medicare rules for coverage of the services described by procedure code 99153 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code 99153 
billed for date of service May 10, 2023. 
 
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 genetic testing provided on March 29, 2023, billed with 
codes 81321, 81351, 81162, 81201, 81307, 81403, 81404, 81405, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that there is no diagnosis code limitation. 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. Although the Local Coverage Article, A57451, the Plan used in their 
decision to deny services does not require a unique identifier, the panel testing 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 March 29, 2023, billed with codes 81321, 81351, 81162, 81201, 81307, 81403, 81404, 
81405, and 81406.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
on a bike at the gym and fainted when you got off so the gym called the fire department. You also say they 
checked your vitals and informed you that should not drive so a friend took you home. The Plan denied your 
request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 15, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97605 provided on May 8, 2023. 
 
You asked the Plan to pay for procedure code 97605. You say that the assistant at surgery for procedure code 
97605 was medically necessary. The Plan denied your request. The Plan says the assistant at surgery for 
procedure code 97605 was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 97605. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 procedure code 97605. Our reviewer says 
that the assistant at surgery for procedure code 97605 was not medically necessary. Our physician reviewer 
found the enrollee was with an open abdomen following emergent repair of a perforated gastric ulcer, reduction 
of gastric volvulus secondary to chronic hiatal hernia, and damage control closure. She was taken to the 
operating room for planned second look laparotomy, pexing gastrostomy tube placement, and delayed primary 
fascial closure. At issue is the need for an assistant surgeon for a negative pressure wound vac device. The need 
for an assistant surgeon is not demonstrated for the placement of an incisional wound vac. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97605 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97605 provided on May 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services and physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary because you need physical therapy for both of your legs. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation does not show that the enrollee is home bound with face to face encounter or provider 
order thus the records do not show that home health skilled therapy services are 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 enrollee's level of function and/or prevent deterioration. Additionally, the 
records do not show that home health skilled nursing services are required to effectively provide treatment, 
care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance 
program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services and physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was untimely due to 
staffing shortages. 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 was 
not billed with an admission date with 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 February 3, 2022, to February 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 1, 2023, to March 31, 
2023. 
 
You asked the Plan to pay for medical services. You say that this should be covered. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on March 1, 2023, to March 31, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guidance Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the enrollee has a clear and documented medical 
necessity of complete cancer removal in this anatomically important area. The Plan denied your request. The 
Plan says there is not enough evidence that this type of radiation therapy guidance is needed or effective for the 
enrollee's skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT is not effective, and it is not considered standard of care for this type of skin cancer. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guidance Radiation Therapy (IGRT) (G6001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 16, 2023. 
 
You asked the Plan to pay for the lab services. You say that samples were sent to you for testing. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 16, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission for the enrollee will provide the 
necessary education to prevent complications and will assist in her recovery. 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's condition is complex and fragile. However, there is enough reason to expect she will 
participate in and benefit from services, to include at minimum physical therapy and occupational therapy, 
physician oversight of polypharmacy, and case manager coordination. These services will make a sustainable 
return home as well as avoid preventable readmissions to the acute hospital. Therefore, the requested IRF 
admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility (SNF), home with home health services, or home with 
outpatient therapy.  
 
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 the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per 
week of rehabilitative services and regular physician evaluation.  The enrollees care needs can be met at a 
lower level of care (ex. SNF/sub-acute rehabilitation).  
 
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 pneumatic compression device (E0676), provided on 
March 21, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says a PCD used for preventative services is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676), provided on March 21, 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 denial poses risk to the enrollee's right to full 
recovery and return to optimal functioning. The Plan denied your request. The Plan says these services are 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 the enrollee is functioning well post hip fracture. Enrollees who are minimal assist in 
the acute hospital following hip fracture repair are usually able to make rapid progress with rehabilitation and 
do not require intensive or complex rehabilitation services. The enrollee is minimal assist for mobility, 
ambulation and toilet transfer. Admission to an inpatient rehabilitation facility is not medically necessary for 
this enrollee.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH placement was requested as 
the enrollee has multiple medical issues that are too complicated for placement in a skilled nursing facility. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for an LTACH admission. 
 
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 the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 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 the services are medically necessary for the enrollee 
to return to a baseline level of function. The Plan denied your request. The Plan says the enrollee can 
reasonably be expected to continue therapies at a lower level of care with similar success.  
 
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 based on the documentation provided, the enrollee does not require the intensity of 
services provided at an IRF. The enrollee is not shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. The enrollees care needs can be met at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.