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

 
We decided that the Plan does not have to pay for SNF care provided from April 19, 2023, to April 24, 2023. You asked the Plan to pay for SNF care. You say that services the enrollee required and received during the 
period in question are coverable. The Plan denied your request. The Plan says the enrollee did not meet the 
criteria for SNF care for the period in question. 
 
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 pay for 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 based on the limited documentation provided, the enrollee did not have documented 
skilled nursing and/or skilled therapy needs. Daily skilled services are not shown to have been required to 
establish a maintenance program or to prevent deterioration of the enrollees condition.   
 
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 pay for SNF care provided from April 19, 2023, to April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided April 11, 2023. 
 You asked the Plan to pay for the orthosis. You say that please see attached medical records. The Plan denied 
your request. The Plan says services not documented in patient's medical records.  
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records provided do not support the need for this back brace.  
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided April 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95939) provided on January 31, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis 
code is not covered for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes support medical 
necessity for code 95939.  
 
We looked at the file and Medicare rules. Per the applicable LCA, the billed diagnosis codes, M48.04, M48.05, 
and M48.061, do not support medical necessity for code 95939. 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 the services (95939) provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861 and 95999 for date of service May 
17, 2022. 
 
You asked the Plan to pay for procedure codes 95861 and 95999. 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. 
 
We find that CPT codes 95861 and 95999 are not supported in the medical record. Specifically, no records 
were received to support code 95861 for date of service May 17, 2023. The submitted medical records do not 
include documentation of eight or more channels. Therefore, code 95999 is not supported. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 95861 and 95999 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95861 and 95999 for date of 
service May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) electrocardiogram, routine 
ECG with at least 12 leads (93000) and smoking and tobacco use cessation counseling visit (99406) provided 
on May 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that please reconsider the payment of this claim. You 
have attached supporting documentation to the appeal. The Plan denied your request. The Plan says these 
services are not covered when rendered by an out-of-network provider. 
 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 the outpatient office visit (99204) 
electrocardiogram, routine ECG with at least 12 leads (93000) and smoking and tobacco use cessation 
counseling visit (99406) provided on May 8, 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 procedure codes 99223, 99232, and 99239 for date of service 
February 19, 2023, to February 22, 2023. 
 
You asked the Plan to pay for procedure codes 99223, 99232, and 99239. 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. 
 
We find that CPT codes 99223, 99232, and 99239 are not supported in the medical record. Specifically, the 
medical records do not include an evaluation and management note for the billed date of service; therefore, 
code 99232 is not supported. The medical records do not include a discharge day evaluation and management 
note for the billed date of service; therefore, code 99239 is not supported. The medical records do not include 
an evaluation and management note for the billed date of service; therefore, code 99223 is not supported. Based on this information, we decided that Medicare rules for coverage of procedure codes 99223, 99232, and 
99239 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99223, 
99232, and 99239 for date of service February 19, 2023, to February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service June 7, 2023. 
 
You asked the Plan to pay for code G0483. 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
include a laboratory order for definitive/confirmative drug tests or 22 or more drug classes. Based on this 
information, we decided that Medicare rules for coverage of code G0483 have not been met. Therefore, we 
decided that the Plan does not have to pay for code G0483 for date of service June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4221 and A4222 billed for date of service 
May 5, 2023, to May 11, 2023. 
 
You asked the Plan to pay for procedure codes A4221 and A4222. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says procedure codes A4221 and A4222 are not 
covered by Medicare. 
 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 codes A4221 and A4222 have a status indicator of X on the Physician Fee Schedule. 
This means that procedure codes A4221 and A4222 are not payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes A4221 and A4222 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes A4221 and A4222 billed for date of service May 5, 
2023, to May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar sacral orthosis provided on June 28, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no history of a patient/provider relationship with the referring physician. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of any fracture or instability. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a lumbar sacral orthosis provided on June 28, 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 has been currently participating well in 
physical and occupational therapy and is demonstrating way below the baseline capacity. The enrollee is 
limited with activity due to dizziness and positive orthostatic hypertension and will be unsafe to go home due 
to very high fall risk. The Plan denied your request. The Plan says the enrollee's condition does not meet all the 
requirements for inpatient rehabilitation admission. The Plan says services may be provided 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 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 medical 
records 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. It is not a 
reasonable expectation that the enrollee 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: 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 can tolerate intensive therapies for three 
hours a day five days a week. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 for date of service February 13, 2023. 
 
You asked the Plan to pay for procedure code 99214. 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 M54.41 (Lumbago with sciatica, right side)/M54.42 (Lumbago with 
sciatica, left side) has an Excludes1 note in relation to M54.50 (Low back pain, unspecified). This means that 
the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure code 99214 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99214 for date of service February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 4, 2023, billed with 
codes 87150, 87481, 87486, 87500, 87640, 87641, 87651 and 87801. 
 
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 May 4, 2023, billed with codes 87150, 87481, 87486, 87500, 87640, 87641, 87651 and 
87801.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 home health physical therapy visits. 
 
You asked the Plan to pre-approve 5 home health physical therapy visits. You say that you would like to 
request reconsideration of the denied home health physical therapy visits and that the services requested are 
medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 5 home health physical therapy visits. 
Our reviewer says that the services are medically reasonable and necessary. Our physician reviewer found the 
clinical documentation shows that the enrollee continues to require physical assistance with bed mobility, 
transfers with continued medical equipment evaluation (attempting to progress from lift to slide board/squat 
pivot transfers). Thus, the enrollee is not stable on a home exercise plan and would require the assistance of a 
skilled physical therapist to meet appropriate home health PT goals.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health physical therapy visits have been met. Therefore, we decided that 
the Plan has to pre-approve 5 home health physical therapy visits.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0601 billed for March 12, 2023, to April 6, 
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 the number of units billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 26 units of CPT code E0601 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code E0601. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
E0601 billed for March 12, 2023, to April 6, 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 currently meets full inpatient 
rehabilitation criteria. The Plan denied your request. The Plan says the enrollee's condition does not meet all the 
requirements for inpatient rehabilitation admission. The Plan says services may be provided 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 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 medical 
records 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. It is not a 
reasonable expectation that the enrollee 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.