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 need rehabilitation because you are not well enough 
to go home. You say you need the acute rehabilitation to regain full function. The Plan denied your request. 
The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of care such 
as a skilled nursing facility.  
 
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 you were admitted for respiratory failure, congestive heart failure and chronic 
obstructive pulmonary disease (COPD). Your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 90791 provided on May 26, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for code 90791. You say that these services were provided in good faith, and the 
provider relied on the facility to get authorization. The Plan denied your request. The Plan says 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 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. 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 code 90791 provided on May 26, 2023, by an out-
of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 12, 2023, to 
May 11, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
timely. The Plan denied your request. The Plan says the NOA has not been billed with the correct admission 
date. You billed the NOA with an admission date of March 10, 2023.  However, the claim was billed with an 
admission date of March 13, 2023.  These dates need to match. 
 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 April 12, 2023, to May 
11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5102 billed for dates of service October 21, 
2022, to October 31, 2022. 
 You asked the Plan to pay for procedure code S5102. You say that you would like these claims reconsidered. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5102 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5102 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5102 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5102 billed for dates of service October 21, 2022, to October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80162) provided on February 2, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for out-of-network laboratory services. You say that these services were medically 
necessary, and the enrollee would not have a choice in laboratory. The Plan denied your request. The Plan says 
out-of-network care is covered only in certain limited circumstances which have not been met in this case. 
Neither the referring provider nor the rendering provider are in-network with the Plan. 
 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. 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 laboratory services (80162) provided on February 
2, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on April 5, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says there is insufficient information 
in the records provided to support that these services were medically necessary and specifically ordered by the 
enrollee's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the records provided include a physician order with a request for "Urine MCT (All-in-One)" 
panel. This document does not include further information to specify what services or drugs are requested for 
testing in this panel. Without this information, we cannot verify that the services provided were the services 
requested by the enrollee's treating physician, or that they were reasonable or necessary. Therefore, we decided 
that the Plan does not have to pay for definitive drug testing (G0483) provided on April 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral CT scans of the leg. 
 
You asked the Plan to pre-approve bilateral leg CT scans. You say that approval for the enrollee's surgery has 
been received., and the requested imaging is necessary to assist with obtaining prostheses. The Plan denied 
your request. The Plan says the requested imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 bilateral leg CT scans. Our reviewer 
says that the requested imaging in not medically necessary. Our physician reviewer found the provided records 
document that the Plan has approved routine total knee replacements, not the MAKO robotic technique for 
the bilateral total knee replacements for which the CT scans are reported to be necessary. Given that the records 
do not support the MAKO robotic technique has been approved, the CT scans do not meet Medicare criteria for 
coverage.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral leg CT scans have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral CT scans of the leg.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on July 19, 2022, billed with 
codes 87481, 87798, 87491, 87591, 87661, 87640, 87653, 87496 and 87529. 
 
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 July 19, 2022, billed with codes 87481, 87798, 87491, 87591, 87661, 87640, 87653, 87496 
and 87529.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 25, 2022, 
to March 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
and should be accepted for timely filing. 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 February 25, 2022, to 
March 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right L3-L5 lumbar facet joint radiofrequency 
ablation (RFA) (64635, 64636). 
 
You asked the Plan to pre-approve the L3-L5 lumbar facet joint RFA . You say that the service is medically 
necessary.  The Plan denied your request. The Plan says the L3-L5 lumbar facet joint RFA is 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 pre-approve the L3-L5 lumbar facet joint RFA. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the repeat RFA did NOT provide adequate relief. The criteria are at least 
50% pain relief for 6 months, and since this was not achieved, the request is deemed not medically reasonable 
and 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 L3-L5 lumbar facet joint RFA have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the right L3-L5 lumbar facet joint radiofrequency ablation (RFA) 
(64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs of the wheelchair headlight kit. 
 
You asked the Plan to pre-approve repairs of the wheelchair headlight kit. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says repairs to a wheelchair headlight is not 
covered under Medicare or the Plan, as a wheelchair headlight is not covered under Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve repairs of the wheelchair headlight kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
February 8, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that few details are provided about the 
present illness. The examination is not comprehensive. The medical decision making is not of high 
complexity. As such, the billing of CPT 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the device will gauge fluid retention. 
The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in peer-
reviewed literature.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure. Published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99232 billed for date of service January 23, 2023. 
 
You asked the Plan to pay for code 99232. You say that 99232 should be covered because it was medically 
necessary and supported in the documentation. The Plan denied your request. The Plan says 99232 is denied 
because payment for this service is bundled into payment for 99233, billed on the same date of service by a 
provider of the same group. 
 
The Plan follows Medicare rules. Medicare rules say that providers must code claims correctly. 
 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 code 99232. Our reviewer says that separate 
payment of code 99232 is not supported by the documentation provided. Our physician reviewer found the 
medical records submitted include one evaluation and management service.  The Plan states they were billed 
for two evaluation and management services on the same date of service, and this resulted in unbundling, 
however records from two separate evaluation and management procedures were not submitted. As a result. 
code 99232 and modifier 25 (significant, separately identifiable evaluation and management (E/M) service 
performed by the same physician or other provider on the same date) cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99232 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99232 billed for date of service January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service November 4, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says this code is not supported by the medical record. 
 
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 Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found this enrollee has a history of heart failure and chronic 
obstructive pulmonary disease, and they presented with increased shortness of breath. They were treated with 
IV diuresis, steroids, and antibiotics. In this case, the documentation supports a comprehensive exam, but not a 
comprehensive history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service November 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 6, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnoses billed are payable. 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 F30.9 has an Excludes1 note in relation to  F31.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on January 6, 2023.