Persius/hicric huggingface dataset:
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 would like reconsideration as you need the 
therapy services. The Plan denied your request. The Plan says you do not meet the medical necessity criteria 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does require physical therapy and occupational therapy services, but the medical records provided do not 
clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. Provided medical 
records do not support that the intensive inpatient rehabilitation therapy program is necessary and that therapy 
at a lower level of care such as home with outpatient treatment or home health or in a skilled nursing facility is 
not appropriate for the patient. Based on the medical records provided, the enrollee would be expected to 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. However, the medical records do not support a complexity of needs to require an acute 
inpatient rehabilitation facility over other options including home health treatment or a skilled nursing facility.  
 
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 requested IRF services are necessary for the 
enrollee to regain their independence. The Plan denied your request. The Plan says admission to an IRF 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 the complexity of the enrollees 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 the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The member 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 45380 and G0500 billed for date of service 
May 9, 2023. 
 You asked the Plan to pay for the billed services. You say that the medical records support the billed codes. 
The Plan denied your request. The Plan says the billed codes 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 45380 is colonoscopy, flexible; with biopsy, single or 
multiple. The definition of code G0500 is moderate sedation services provided by the same physician or other 
qualified health care professional performing a gastrointestinal endoscopic service.  
 
We find that CPT codes 45380 and G0500 are not supported in the medical record. The records provided 
include an evaluation prior to colonoscopy. However, the records do not include a colonoscopy with sedation. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 45380 and G0500 billed for 
date of service May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service June 24, 
2022.   
You asked the Plan to pay for procedure code 87798. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service June 24, 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 your health is declining, and you need 
care to fight for your life. The Plan denied your request. The Plan says admission to an LTACH 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 there are no services available at the LTACH that you require that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH is 
not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95886, defined as needle electromyography, each 
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (list separately in addition to code for primary procedure)and 95909, defined as nerve 
conduction studies; 5-6 studies, billed on December 19, 2022. 
 
You asked the Plan to pay for 95886 and 95909. You say that 95886 and 95909 should be paid as billed 
because they are supported in the medical record and the diagnosis codes assigned support medical necessity. 
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 G56.22 has an Excludes1 note in relation to M54.12. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for 95886 and 95909 have not been met. Therefore, we decided that the Plan does not have to pay 
for codes 95886, defined as needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels (list separately in addition to code for 
primary procedure)and 95909, defined as nerve conduction studies; 5-6 studies, billed on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nail Fungal Infection polymerase chain reaction (PCR) 
Panel provided on November 7, 2022. 
 
You asked the Plan to pay for the Nail Fungal Infection PCR Panel. You say that the provided Nail Fungal 
Infection PCR Panel was medically necessary.  The Plan denied your request. The Plan says the provided Nail 
Fungal Infection PCR Panel was not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Nail Fungal Infection PCR Panel. Our reviewer says that the provided Nail Fungal Infection PCR Panel was not medically necessary. Our physician 
reviewer found current standard of care for investigation of onychomycosis in a toenail is to perform a 
potassium hydroxide (KOH) and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, 
and specific. It is unclear as to why this enrollee's toenail specimen required PCR testing when other less 
expensive and efficacious lab tests (KOH and fungal culture) are available. Therefore, the provided PCR 
testing of this enrollee's toenail was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Nail Fungal Infection PCR Panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the Nail Fungal Infection polymerase chain reaction (PCR) Panel 
provided on November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81529) provided on January 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that this claim was denied in error. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81529) provided on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2313, and one unit of E2377 are allowed. The Plan denied your request. The Plan says that although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee requires power elevating leg rests for 
positioning of their lower extremities and lower extremity spasticity. The complexity of the enrollee's seating 
and positioning needs necessitates a more complex group 3 power wheelchair base. Our reviewer found that the 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base and the three power options via a joystick. Our physician reviewer also found that these 
components are required to operate 3 or more power options on a group 3 power wheelchair. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided by a non-contracted 
provider on June 22, 2023. 
 
You asked the Plan to pay for behavioral health services. You say that this provider is an eligible provider of 
outpatient mental health services. The Plan denied your request. The Plan says that this provider is not eligible 
for Medicare enrollment. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, 
a provider must be enrollee in Medicare. A Mental Health Counselor (MHC or LMHC) is not eligible to enroll 
in the Medicare program so is not payable. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of behavioral health services have not been met. Therefore, we decided that the Plan does not have to 
pay for behavioral health services provided by a non-contracted provider on June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and water 
circulating heat pad with pump (E0217) 
 
You asked the Plan to pay for a pneumatic compression device and water circulating heat pad with pump. You 
say that you have outlined how this enrollee's medical necessity actually meets the guidelines that qualify for coverage. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. A water circulating heat pad with 
pump (E0217) 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, these items are not a covered benefits 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 a pneumatic compression device (E0675) and water circulating heat pad with pump (E0217)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy provided from May 22, 2023, to  
June 5, 2023. 
 
You asked the Plan to pay for the massage therapy. You say that you were told that the massage therapy would 
be covered. The Plan denied your request. The Plan says massage therapy performed by a massage therapist is 
not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy provided from May 22, 2023, to  
June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 13, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on March 17, 2023. 
 
You asked the Plan to pay for podiatry services. You say that the services were 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 podiatry services 
provided on March 17, 2023.
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 enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a Long-
Term Acute Care Hospital (LTACH). 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning 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 the urinary tract infection PCR panel coded as 87511, 87500, 
87481, 87556, 87563, 87641, 87653 and 87798, provided April 2, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration and payment in 
full for the molecular PCR test performed. 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 laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection PCR 
panel coded as 87511, 87500, 87481, 87556, 87563, 87641, 87653 and 87798, provided April 2, 2023.