Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from November 11, 2022, to 
December 30, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this specialty is not eligible to furnish mental health services. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
November 11, 2022, to December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from March 30, 2021, to 
April 3, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says reasonable clinical evidence is not found 
within the documentation to valid diagnosis code J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that in this case, there was no clinical or laboratory evidence of acute respiratory failure with 
hypoxia. The review has determined that  the documentation did not support diagnosis code J96.01 - acute 
respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from March 30, 2021, to April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
August 25, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
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.  
 
 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, this item is not a covered benefit 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 the pneumatic compression device (E0676) provided on August 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on November 23, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says that the code used to report the services provided 
is 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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records provided support 
that drugs from 15-21 classes were tested in this case. Based on this information, we decided that Medicare 
rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive 
drug testing (G0482) provided on November 23, 2022.  
 
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: 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 is stable for transfer and 
requires prolonged and intensive skilled services. The Plan denied your request. The Plan says it is not safe for 
the enrollee to leave the hospital at this time because having ongoing neurologic issues preventing weaning 
from mechanical ventilation and having continued vomiting and inability to tolerate enteral feedings that 
requires further management. 
 
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 there are no services available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is receiving appropriate in-
patient acute care and does not require transfer to a Long-Term Acute Care Hospital. The Plan denied your 
request. The Plan says this is the safest discharge plan, allowing the highest potential for the enrollee's 
recovery, preventing further deterioration and the best use of medical management. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirement for long term acute care. Services needed may be provided safely in 
a lower level of care. Services needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has suffered from a stroke with left sided 
weakness. Inpatient is needed to get intense rehabilitation that is needed for the wellbeing of the enrollee. The 
Plan denied your request. The Plan says the enrollee's medical condition requires further evaluation and 
treatment in the acute care hospital. 
 
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. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's current treatment, including controlling and adjusting the breathing machine can be provided in an 
alternate setting or in the current hospital setting. Once the enrollee is stable for transfer to an alternate setting 
there are facilities in-network, such as sub-acute or skilled facilities, that can meet these needs. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99053 and 99285 rendered on August 4, 
2021. 
 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 the denied codes is: 
 
CPT 99053: 
 
Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service 
 
CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: 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 presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function 
 
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 in terms of 99285, the records do 
not support a comprehensive history or physical examination or medical decision making of high complexity. 
The enrollee was stable, and did not have signs of infection or other severe or complex condition. The records 
also do not support that the presenting problem was of high severity, posing immediate threat to the patient.  
 
Additionally, we find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99053 is not separately payable. 
 
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 procedure codes 99053 and 99285 rendered on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services coded as 97110, 97116, 97140 
97530 provided on September 26, 2022, to December 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that please review the attached necessary 
documents to prove the medical necessity for services that were provided as per medical necessity to restore the 
functional abilities of the enrollee. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 physical therapy services coded as 97110, 
97116, 97140 97530 provided on September 26, 2022, to December 13, 2022, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patent foramen ovale (PFO) closure-device placement 
(93580). 
 
You asked the Plan to pre-approve a PFO closure-device placement. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 a PFO closure-device placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee is currently receiving anticoagulation with Eliquis. Guidelines 
point to a recommended age limit of 60 years for the requested procedure. There is insufficient documentation to support the medical necessity for the requested PFO closure in the enrollee's 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 a PFO closure-device placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a patent foramen ovale (PFO) closure-device placement (93580).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records show that the enrollee has both back pain and leg pain symptoms. Leg symptoms are a 
contraindication to the Intracept procedure. 
 
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 pre-approve thermal destruction of intraosseous basivertebral nerve.
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 does require a LTACH level 
of care and is stable for discharge. The Plan denied your request. The Plan says the enrollee's records do not 
show the need for continued treatments that can only be given in a hospital setting. When ready to leave the 
hospital, services needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 procedure codes 81291 and 81479 for date of service 
October 26, 2022. 
 
You asked the Plan to pay for procedure codes 81291 and 81479. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not payable as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81291 and 81479 are not supported in the medical record. Specifically, code 81291 
was billed with modifier GZ. This means this code is specifically not covered. Code 81479 is not covered 
because 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. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 81291 and 81479 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 81291 and 81479 for date of service October 26, 2022.