Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 10, 2022, to 
July 9, 2022. 
 
You asked the Plan to pay for the home health services. You say that you were told that there is missing 
information on your claim. You say that your claim was submitted complete. The Plan denied your request. 
The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 10, 2022. The NOA was not received by the Plan until July 25, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
June 10, 2022, to July 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
tertiary level of care orthopedics provider. 
 
You asked the Plan to pre-approve the physician's services to be provided by the requested tertiary level of care 
orthopedics provider. You say that the services are medically necessary. The Plan denied your request. The 
Plan says the rules for tertiary care (a higher level of care) are not 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 services with a tertiary level of care 
orthopedics provider. Our reviewer says that the requested tertiary orthopedics physician's services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that based on the 
medical records provided there is no documentation that the health Plans approved community orthopedic surgeon would not be able to provide necessary care that you require to meet the standard of care for your 
condition. The tertiary level orthopedic care does not appear to be necessary based on the provided records. 
 
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 physician's services to be provided by the requested tertiary level of care 
orthopedics provider have not been met. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested tertiary level of care orthopedics provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal (81479) provided February 20, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you provide the Guardant Reveal molecular 
diagnostic test at the request of the ordering physician. The Plan denied your request. The Plan says this test is 
considered investigational and unproven as there is insufficient evidence in safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per the DEX Diagnostic Exchange, Guardant Reveal is not covered 
by Medicare. National Comprehensive Cancer Network (NCCN) does not support circulating tumor 
deoxyribonucleic acid (DNA) (ctDNA) for stage II breast cancer. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant Reveal (81479) provided February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin grafting services with tissue substitutes (Matrion) 
(15275, Q4201). 
 
You asked the Plan to pre-approve Matrion for skin grafting. You say that these services are necessary and 
would be an appropriate treatment for this enrollee. The Plan denied your request. The Plan says this service is 
not medically necessary as it is still considered experimental or investigational. 
 
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 Matrion for skin grafting. 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 a healing wound after foot arthrodesis with 
standard of care therapy. 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 elements of the coverage criteria 
are not satisfied. The requested service is not 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 Matrion for skin grafting have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skin grafting services with tissue substitutes (Matrion) (15275, Q4201).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete blood count (85025) provided January 5, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you did your procedure stat prior to the 
hospital visit. Please consider this for payment as you treated the enrollee initially and sent them to the 
emergency room. The Plan denied your request. The Plan says the documentation submitted do not support the 
services provided on January 5, 2023. 
 
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 85025 is blood count; complete (CBC), automated 
(hemoglobin (HGB), hematocrit (HCT), red blood cells (RBC), white blood cells (WBC) and platelet count) 
and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the result date of March 14, 
2023, does not match the visit date of January 5, 2023. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for complete blood count (85025) provided January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low air loss mattress (E0277). 
 
You asked the Plan to pre-approve a low air loss mattress. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. The Plan follows Medicare rules. Medicare rules say that a low air loss mattress is covered when at least one of 
the criteria listed in the Medicare rules section are met. 
 
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 low air loss mattress. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the provided records in this 
case do not document the enrollee has multiple stage 2 pressure ulcers located on the trunk or pelvis. The 
provided documentation also does not show the enrollee has large or multiple stage 3/4 pressure ulcer(s) on the 
trunk or pelvis or a myocutaneous flap/skin graft for a pressure ulcer on the trunk or pelvis within the past 60 
days. 
 
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 low air loss mattress have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a low air loss mattress (E0277).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging (71275) provided on January 14, 2023. 
 
You asked the Plan to pay for the imaging. The Plan denied your request. The Plan says this service is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that when a comparative imaging study is performed 
to assess potential complications or completeness of a procedure (e.g., post-reduction, post-intubation, post-
catheter placement, etc.), the professional component of the CPT code for the post-procedure imaging study is 
not separately payable and shall not be reported.  
 
We looked at the file and Medicare rules. Per Medicare rules, the requested imaging is not separately payable 
in this case. Based on this information, we decided that Medicare rules for coverage of the imaging have not 
been met. Therefore, we decided that the Plan does not have to pay for the imaging (71275) provided on 
January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wet wipes (E1399). 
 
You asked the Plan to pre-approve the wet wipes. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the wet wipes (E1399).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 26, 2022, to 
May 25, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 26, 2022. The NOA was not received by the Plan until January 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from April 26, 2022, to May 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of 7 
additional PT visits The Plan denied your request. The Plan says the request is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that based on the medical records provided there is no documentation 
that the 7 denied PT visits meet Medicare criteria for coverage. Records do not support that the complexity of 
your condition are such that the skills of a professional therapist are required to achieve further improvement in 
your symptoms or functional status. Further utilization of the home exercise program appears appropriate. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient Evaluation and Management (EM) services 
provided on April 25, 2022, billed with code 99223. 
 
You asked the Plan to pay for the Inpatient Evaluation and Management (EM) services provided. You say that 
the claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation 
does not support 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 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 physician 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 Inpatient Evaluation and Management (EM) services 
provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the 
enrollee is an 85-year-old female who was seen on April 25, 2022. The documentation from that date describes 
the enrollee as falling (ground level) hitting her head and landing on her knees with moderate pain reported 
without other symptoms. Physical findings were expanded and detailed. X-ray showed bilateral tibial fractures. 
The plan included orthopedic consult, physical therapy, and home meds. However, the code, 99223, is not 
sufficiently supported as the documentation does not support a comprehensive history and does not sufficiently 
support medical decision-making of high complexity as required.  
 
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 Inpatient Evaluation and Management (EM) services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for Inpatient Evaluation and Management 
(EM) services provided on April 25, 2022, billed with code 99223.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TENS device provided on September 26, 2022. 
 
You asked the Plan to pay for a TENS device. You say that the treatment at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the treatment at issue is not a Medicare-covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is not reasonable and necessary for the 
treatment of CLBP. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a TENS device have not been met. Specifically, the record indicates TENS was requested for 
treatment of CLBP. Therefore, we decided that the Plan does not have to pay for a TENS device provided on 
September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitation needs warrant an IRF level of care to achieve a safe and sustainable discharge. 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 that 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, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. There 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are all fall risk and are not able to walk with a 
walker. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on January 
9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on January 12, 
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 the code used to report the 
services provided is not supported in the documentation. 
 
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, 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 records provided 
support that only 20 drug classes were tested in this case. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay 
for definitive drug testing (G0483) provided on January 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
22, 2021, to November 23, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were reasonable and 
necessary. The Plan denied your request. The Plan says the enrollee could have safely been treated in an 
outpatient setting; therefore, this inpatient admission was not medically necessary. 
 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department with report of difficulty caring 
for himself. He was found to be mildly weak and with pressure sores which were unchanged from prior 
examination. Labs were unremarkable, vitals were stable, and plans were made for placement and wound care. 
Based on the provided documentation, the enrollee only required short-term observation status without 
expectation of needing hospital services that would likely cross 2 midnights.  
 
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 pay for the acute inpatient hospital care provided from November 22, 2021, to November 
23, 2021.