Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on April 17, 2023. 
 
You asked the Plan to pay for genetic testing. You say that this testing has been determined to be medically 
reasonable and necessary for management of the enrollee's condition. The Plan denied your request. The Plan 
says that this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The record does not include prior notice from the Plan that this testing would not be 
covered. Without this information, we cannot determine whether the lab order made constituted plan-directed 
care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified. 
Therefore, we decided that the Plan has to pay for genetic testing provided on April 17, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 provided on April 
17, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and 96521. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. 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 96365, 96366, and 96521 
provided on April 17, 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 services are medically necessary for the 
enrollee's care needs. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF.  
 
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 enrollee is unable to participate in or benefit from intensive rehabilitation. 
Therefore, the requested services cannot be approved as the enrollee would not meet the criteria for admission.  
 
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. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving the 
appropriate inpatient acute care and does not require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving all indicated care in the acute care hospital. There are no 
specific therapies that they would receive at a LTACH that they are not currently receiving. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Orthovisc is medically reasonable and necessary for the enrollee. The 
documentation does not support that the Orthovisc is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
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 this is the only level of care that is a safe 
option for the enrollee to receive the services needed. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 87653, 87798, and 87801 billed for date of 
service December 5, 2022. 
 
You asked the Plan to pay for procedure codes 87653, 87798, and 87801. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
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. In this case, we have confirmed that codes 
87653 and 87798 are column II codes to column I code 87801. The -XU modifier is not supported as a separate 
and distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been met. 
 
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 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. We find that CPT code 87801 is not supported in the medical record. Specifically, the 
records show that multiple infectious agent detection was performed but the number of units billed is not 
supported. 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 codes 87653, 87798, and 87801 billed 
for date of service December 5, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health physical therapy (G0151 x5). 
 
You asked the Plan to pre-approve home health services. You say that this is 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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that the enrollee has progressive rheumatological disease (rheumatoid arthritis) and 
continues to lose range of motion (ROM) in upper limbs and right knee resulting in progressive functional 
impairments (documented by provider). Clinical documentation shows that the enrollee still requires assistance 
with mobility tasks with worsening ROM per therapy notes. With the progressive clinical features documented 
the enrollee would be expected to require 5 additional home health physical therapy visits. The records show 
that skilled therapy services are required in the home setting to effectively provide treatment, care, and/or 
services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to 
maintain the enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve home health physical therapy (G0151 x5).  
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 provided on February 27, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported 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. 
 In this case, the CPT Code Manual definition of code 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, no records were provided to 
support the units billed for code 87798. Based on this information, we decided that Medicare rules for coverage 
of procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87798 provided on February 27, 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's medical management and rehab needs 
require an inpatient rehab stay and close physician supervision. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. 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 99233 billed for dates of service March 7, 
2023, to March 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the level of care 
billed. The Plan denied your request. The Plan says the billed codes remain 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 99233 is subsequent 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, 50 minutes must be met or exceeded. 
 
 We find that CPT code 99233 is not supported in the medical record. The records show that the enrollee 
presented with constant abdominal pain in the right lower quadrant. The enrollee was treated with pain 
medication. The records do not show a high level of medical decision making was provided. The records do not 
indicate the amount of time spent on each date as required. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 billed for dates of service March 7, 2023, to March 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior non-segmental instrumentation (22480), and 
arthrodesis (22612). 
 
You asked the Plan to pre-approve posterior non-segmental instrumentation, and arthrodesis. You say that this 
is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature 
indicates that this service is considered experimental and investigational as it is not identified as widely used 
and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical 
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 posterior non-segmental 
instrumentation, and arthrodesis. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the HA Minuteman G3-R MIS 
Fusion Plate is intended for use with bone graft material and is not intended for stand-alone use. In addition, 
fusion indications within guidelines/literature for (existing or potential intraoperative) instability have not been 
documented and/or met in this case. In addition, there are multiple alternate pain generators plausibly 
significantly contributing to the clinical condition that have not been fully documented as having been excluded 
and/or ruled out. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior non-segmental instrumentation, and arthrodesis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve posterior non-segmental instrumentation 
(22480), and arthrodesis (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve injection. 
 
You asked the Plan to pre-approve genicular nerve injection. You say that the enrollee is not functioning well, 
their medication lasts only 4 hours and causes dizziness, their chronic pain was denied a higher dose of 
medication. 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 genicular nerve injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/ investigational procedure.  It is the subject of 
ongoing clinical trials.  Therefore, 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 genicular nerve injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, J1817, and G0108 
provided on March 20, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, J1817, and G0108. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin therapy. 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 96365, 96366, 96521, 
J1817, and G0108 provided on March 20, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from March 20, 2023, to April 18, 
2023. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that 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 January 19, 2023. The NOA was received by the Plan on January 20, 2023. 
As less than 30 days passed between the timely filing date and the NOA receipt, payment can be made on this 
claim. The Plan provided no evidence that the start of care was not January 19, 2023. Therefore, we decided 
that the Plan has to pay for the home health services provided from March 20, 2023, to April 18, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 6, 2022.