Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements 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 that the enrollee was admitted acute on chronic respiratory failure secondary to 
severe pulmonary hypertension and pneumonia. The record indicates that the enrollee is improving but still 
requires acute care services before transitioning to a lower level of care. The enrollee does not require services 
at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility 
is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this member will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve steroid injection. 
 
You asked the Plan to pre-approve a genicular nerve steroid injection. You say that the enrollee meets the 
criteria for the requested procedure. The Plan denied your request. The Plan says the procedure requested does 
not meet the requirements for approval. 
 
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 a genicular nerve steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has knee pain in the setting of an 
imaging study showing a tear of the posterior root attachment of the medial meniscus, effusion, and 
degenerative findings. There is insufficient literature to support the safety and efficacy, as defined by Medicare 
rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The requested service is not 
recommended, as the elements of the coverage criteria are not satisfied.   
 
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 genicular nerve steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a genicular nerve steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 has had a complicated course, including wound infection and delirium. 
Wound care needs are not sufficient to warrant LTACH admission and the enrollee does not require longer-
care needs such as prolonged ventilator weaning. The enrollee is improving and can remain in their current 
setting until the enrollee can be transferred to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Liquid biopsy (F1LCDx) (0239U) provided 
on February 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that the enrollee meets all of the requirements for 
coverage of F1LCDx under the NCD. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 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. The records also show that the enrollee has previously had this same test on the same 
cancer. 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 FoundationOne Liquid biopsy (F1LCDx) (0239U) provided on 
February 19, 2023, by an out-of-network (OON) provider.
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 4, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 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 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 24, 2023, and billed with codes 87801, 87798, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on April 24, 2023, and billed with codes 87801, 87798, and 87481.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that while the enrollee has a history of postural dizzy spells and 
documented premature atrial contractions (PACs) and premature ventricular contractions (PVCs) on 
ambulatory electrocardiogram (ECG) monitoring, there is no documentation provided to suggest a history of 
unexplained syncope, or any other apparent indication for an ILR. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service April 28, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. 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 diagnosis code group I20 has an Excludes1 note in relation to I25.1-. This 
means that diagnosis codes I20.0 and I25.10 cannot be reported together. Based on this information, we 
decided that the Medicare billing rules for the billed services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing billed for date of service April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Triiodothyronine testing (84480) and Vitamin D testing 
(82306) billed for date of service June 6, 2023.  
 You asked the Plan to pay for procedure codes 84480 and 82306. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says payment for code 84480 is bundled into payment 
for code 84481. Vitamin D testing is not a covered benefit in this case. 
 
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 84480 is a column two code to column one code 84481 with a 
modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
The rules also say that Vitamin D testing may not be used for routine or other screening. The claim does not 
report a diagnosis code indicating a Vitamin D deficiency. Therefore, we decided that the Plan does not have to 
pay for Triiodothyronine testing (84480) and Vitamin D testing (82306) billed for date of service June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes C2617, 84132, 82947, 82962, 74328, 43264, 43274, 
J2704, J3010, J2405, and A9270 for date of service February 14, 2023. 
 
You asked the Plan to pay for codes C2617, 84132, 82947, 82962, 74328, 43264, 43274, J2704, J3010, J2405, 
and A9270. 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. 
 
We find that CPT codes C2617, 84132, 82947, 82962, 74328, 43264, 43274, J2704, J3010, J2405, and A9270 
are not supported in the medical record. Specifically, the documentation shows that the enrollee was inpatient 
for this date of service. In addition, the Plan has processed and paid these services on May 18, 2023. Based on 
this information, we decided that Medicare rules for coverage of codes C2617, 84132, 82947, 82962, 74328, 
43264, 43274, J2704, J3010, J2405, and A9270 have not been met. Therefore, we decided that the Plan does 
not have to pay for codes C2617, 84132, 82947, 82962, 74328, 43264, 43274, J2704, J3010, J2405, and A9270 
for date of service February 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found there is no expectation that you will require additional hospital care that 
would likely cross 2 midnights, according to the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided November 13, 2023, to 
December 8, 2023. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation does not support how the enrollee came to the 
servicing provider. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
Review of the file shows that no medical records were provided for these dates of service. In addition, no 
medical records were provided from the enrollee's provider's prior to this date of service to support how the 
enrollee came to the servicing provider. Without medical records, the documentation does not support that the 
billed services were actually provided. In addition, without medical records this means the file does not show 
that the enrollee was homebound.  Therefore, we decided that the Plan does not have to pay for the home health 
services provided November 13, 2023, to December 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 skin substitute. 
 
You asked the Plan to pre-approve Kerecis Omega3 skin substitute. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Kerecis Omega3 skin substitute. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided medical records and review of the current peer-reviewed medical 
literature do not document that use of the Kerecis Omega3 skin substitute has been shown in controlled studies 
in a CMS-approved journal to result in long term health benefits over other more established biologic, synthetic, or biosynthetic materials in patients with diabetic foot ulcers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis Omega3 skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Kerecis Omega3 skin substitute.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance and ground mileage provided on March 22, 
2023. 
 
You asked the Plan to pay for the ambulance and ground mileage. You say that you disagree with the Plan's 
denial. 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 R44.0 (Auditory hallucinations) has an Excludes1 note in relation to F29 
(Unspecified psychosis not due to a substance or known physiological condition). This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance and ground mileage have not been met. Therefore, we decided that the Plan does not 
have to pay for the ambulance and ground mileage provided on March 22, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice or home health services billed with codes Q5001 
and G0299 for June 1, 2023, to June 29, 2023. 
 
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 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 13, 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 these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the hospice or home health services billed with codes Q5001 and 
G0299 for June 1, 2023, to June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on March 20, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the codes 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 99223 is inpatient or observation care, per day for the 
evaluation and management of a patient, that requires a medically appropriate history and/or examination and 
high level of medical decision making, or must meet or exceed 75 minutes of total time. 
 
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 physician services. Our reviewer says that the records do not support the billed code. Our reviewer found the records do not show a high level of medical decision 
making, or at least 75 minutes of time spent on this service. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on March 20, 2023.