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

 
We decided that the Plan does not have to pay for the laboratory panel provided on February 7, 2023, billed 
with codes 87486, 87541, 87581, 87631, 87798, U0004 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on February 7, 2023, billed with codes 87486, 87541, 87581, 87631, 87798, U0004 and U0005.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that your doctor will not let you leave the 
hospital without this device. You say that without it, you have been unresponsive, and it is needed for your 
health and well-being. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary. The enrollee's needs can be met with a BiPAP 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found you were recently hospitalized 
with congestive heart failure manifested by anasarca and bilateral pleural effusions. There was also 
hyponatremia and hypothyroidism.  You became somnolent in the hospital and arterial blood gas (ABG) 
showed acute on chronic hypercarbic respiratory failure.  You improved with BiPAP and average volume-
assured pressure support (AVAPS).  A diagnosis of COPD is mentioned, but you never smoked, apparently did 
not have a prior history of COPD, and there are no pulmonary function tests showing obstructive lung 
disease.  There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  There is no 
documentation of chronic hypercarbic respiratory failure with an ABG done while stable (after resolution of the 
pleural effusions and metabolic abnormalities).  If chronic CO2 retention is present, you may benefit from 
BiPAP during sleep as an outpatient.  The records do not show this has been tried.  Medicare does not cover a 
home ventilator for the treatment of chronic heart failure, or 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee has dementia and cannot talk. The Plan 
denied your request. The Plan says the enrollee's records does not show the need for daily skilled nursing or 
skilled therapy in a SNF setting. The services required are called custodial care. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 17, 2023, to 
April 15, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
and accpted. 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 March 17, 2023, to April 
15, 2023.
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 the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care. 
 
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 is expected to participate in and benefit from IRF services given their advanced age, 
comorbidities, and pattern of falling. The services required include physical therapy, occupational therapy, 
physician oversight of polypharmacy, and case manager coordination of any additional services that might be 
needed to make a sustainable return home as well as avoid preventable readmissions to the acute hospital. 
Therefore, the requested inpatient rehabilitation facility 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 you need this level of care. The Plan denied your 
request. The Plan says your medical condition does not require IRF services, and care can be provided in 
another 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. 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 procedure code 87500 for date of service April 19, 2023. 
 
You asked the Plan to pay for procedure code 87500. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87500 is infectious agent detection by nucleic acid (DNA 
or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT code 87500 is not supported in the medical record. Specifically, there is a more appropriate 
code that should be billed when one or more codes are included in the same panel. This means the validity of 
code 87500 cannot be verified. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87500 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87500 for date of service April 19, 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 enrollee needs this care to regain strength. The 
Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, the 
enrollee needs can be provided at another 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 for date of service April 26, 2023. 
 
You asked the Plan to pay for procedure code 95937. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, the medical records 
submitted indicate that train of four testing was performed. Train of four testing does not fit the criteria for the 
code billed. It is inappropriate to bill the code for neuromuscular junction when train of four testing monitoring 
is performed. Based on this information, we decided that Medicare rules for coverage of procedure code 95937 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 95937 for date 
of service April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, non-segmental home model 
device (E0650). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the denial 
and have provided medical records. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show you do not have lymphedema or chronic venous insufficiency with ulcer. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor, non-
segmental home model device (E0650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81003) billed for date of service May 7, 
2023. 
 You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says the CLIA number submitted on the claim is 
not the same one referenced in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that any independent laboratory performing tests 
covered by CLIA must submit the CLIA number on the claim. Laboratory claims are returned as unprocessable 
if the CLIA number is not submitted, if the CLIA number is submitted but is inconsistent with the CLIA 
format, or if more than one CLIA number is submitted on the claim, except when a reference laboratory is on 
the same claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the CLIA form on the claim does not match 
the one reported in the medical records. It is unclear which CLIA was correct and who provided these services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (81003) billed for date of 
service May 7, 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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement, however, the 
documentation does not support that he would meet criteria for admission to an acute inpatient rehabilitation 
facility. The enrollee can receive further services 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 13-month capped rental of a standard manual 
wheelchair. 
 
You asked the Plan to pre-approve a 13-month capped rental of a standard manual wheelchair. You say that the 
item is medically necessary. The Plan denied your request. The Plan says the records do not show that you are 
unable to use a cane or walker to resolve mobility constraints within the home or that your home provides 
adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a 13-month capped rental of a standard manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (81540) billed for date of service June 12, 
2023. 
 
You asked the Plan to pay for the laboratory test. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this test is not supported with the date of service 
reported. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory test have not been met. Specifically, the records show that the specimen was 
collected on April 5, 2023, the laboratory received the sample on June 2, 2023, and the test was reported on 
June 22, 2023. The date of service reported on this claim is not supported by the medical records provided. 
Therefore, we decided that the Plan does not have to pay for the laboratory test (81540) billed for date of 
service June 12, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on February 13, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that code G0453 has 
not met the LCD diagnosis code requirements, and codes 95938, 95861, and 95937, are duplicate claim lines. 
 
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. The Plan argues that code G0453 has not met the LCD diagnosis code 
requirements, and codes 95938, 95861, and 95937, are duplicate claim lines. However, the Plan has not 
provided documentation of which Local Coverage Determination (LCD) was used to make its decision, nor has 
the Plan provided documentation showing that codes 95938, 95861, and 95937, were previously paid. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the services provided on February 13, 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.