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

 
We decided that the Plan does not have to pay for code 99310 billed for date of service April 7, 2022.  
 
You asked the Plan to pay for code 99310. You say that this patient was in a swing bed, and that is the same 
skilled level of care as at a skilled nursing facility. The Plan denied your request. The Plan says you billed this 
service with an incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill with an accurate Place of 
Service (POS) code to reflect where the services occurred. POS code 21 indicates that the services occurred in 
an inpatient hospital setting.  POS code 31 indicates that the services occurred in skilled nursing facility setting. 
 
In this case, you billed the code in question with POS code 31, indicating that the services occurred in a skilled 
nursing facility setting.  However, the patient was in an inpatient hospital setting.  This is true even if the 
patient is receiving skilled nursing-level services within an inpatient hospital.  POS code 21 should still be 
billed in this scenario, as the patient is not physically in a skilled nursing facility.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99310 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99310 billed for date of service April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevator (E2300), elevating leg rests 
(E1012), and an expandable controller (E2311, E2313, E2377) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair features. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the requested features are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Expandable Controllers and Elevating Leg Rests are 
covered when medically necessary. Power seat elevation features 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 power wheelchair features. Our 
reviewer says that the requested features are not medically necessary. Our physician reviewer found under 
Medicare rules, a power seat elevation feature is not eligible for coverage. The records show that the enrollee is 
capable of operating the power features using the standard switches, and there is no medical documentation 
showing that the enrollee meets coverage criteria for elevating leg rests. 
 
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 power wheelchair features have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevator (E2300), elevating leg rests (E1012), and an 
expandable controller (E2311, E2313, E2377) for an approved power wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is mentally incapable of dosing self 
with insulin and is unsafe to be alone. Services needed may be provided safely in a lower level of care. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements.  
 
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 pre-approve 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 the enrollee does not have any parental medication; complex wound care or nutrition 
given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical 
problems. The enrollee's physical function is at or near the enrollee's baseline and the enrollee can receive 
services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 
medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient metal healthcare provided by an out-of-network (OON) 
provider from May 2, 2022, to May 17, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that that this was medically 
necessary. The Plan denied your request. The Plan says that this was not authorized. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment. Medicare rules also 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. 
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the enrollee met criteria for out-of-network inpatient treatment. Our physician reviewer 
found the records show that the enrollee was a danger to herself as she presented with auditory hallucinations 
and suicidal ideation and required active treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pay for inpatient metal healthcare provided by an out-of-network (OON) provider from 
May 2, 2022, to May 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on November 15, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 3, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the anesthesia services have not been met.  Therefore, we decided that the Plan does not have to pay for anesthesia services provided on November 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection rendered on August 16, 2022. 
 
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 denied codes are not supported and cannot be separately reimbursed. 
 
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 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87640: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 
 
CPT 87641: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique 
 
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 the laboratory report does not 
support the use of modifier -59 for distinct procedural service. The laboratory report documents list of 
"organisms tested - not detected." These procedures would be included in either CPT 87150 or CPT 87641. 
 
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 infectious agent detection rendered on August 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 pre-approve 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 you have made progress with therapy, there is no indication that transfer to a skilled 
nursing facility is required. You can continue to receive skilled rehabilitation services at the current IRF or be 
stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not 
offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation services is 
not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 11, 2022, to 
December 2, 2022. 
 You asked the Plan to pay for the home health services. You say that your final claim was billed correctly. 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 October 12, 2022. The NOA was not received by the Plan until January 2, 
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 home health services provided 
from November 11, 2022, to December 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. 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 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 pre-approve 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 that the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a 
lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA genetic testing provided on March 23, 2022. 
 
You asked the Plan to pay for PrismRA genetic testing. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says this molecular pathology testing has not been approved 
through the MolDX contractor. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. 
 
We looked at the file and Medicare rules. Medicare records do not support that the genetic test at issue has been 
approved through the MolDX contractor. Based on this information, we decided that Medicare rules for 
coverage of PrismRA genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pay for PrismRA genetic testing provided on March 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 10, 2022, to May 
9, 2022.  
 You asked the Plan to pay for the home health services. You say that the NOA is on file. The Plan denied your 
request. The Plan says although you claim that the NOA was submitted, there is no NOA on file.  
 
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 10, 2022. The NOA has not been received by the Plan, so no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided from April 10, 2022, to May 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99283 billed for date of service December 15, 2022. 
 
You asked the Plan to pay for code 99283. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 30, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for code 99283 have not been met.  Therefore, 
we decided that the Plan does not have to pay for code 99283 billed for date of service December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) with a primary care physician 
(PCP) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the visit should be covered because you 
changed plans due to your doctor leaving your previous plan.  The Plan denied your request. The Plan says you 
must choose a network provider to be your PCP. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99203) with a primary care physician (PCP) to be provided by an out-of-network (OON) 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by a network provider. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for an approved power 
wheelchair (E2313, E2377, E2311). 
 
You asked the Plan to pre-approve the expandable controller. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller. Our reviewer 
says that the expandable controller is not medically necessary. Our physician reviewer found the records show 
that the enrollee is able to operate the wheelchair's power functions by their own switches. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller for an approved power wheelchair (E2313, E2377, 
E2311).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is very disoriented, and cannot walk 
without assistance and is in no condition to be independent.  The Plan denied your request. The Plan says the 
enrollee's documentation does not fulfill the requirements for covering skilled nursing facility. 
 
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 pre-approve 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 the enrollee's physical function is at or near the enrollee's baseline and the enrollee 
can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is 
not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 27487-RT billed for date of service December 1, 2022. 
 
You asked the Plan to pay for code 27487-RT. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed this service with an incorrect diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should bill the appropriate 
International Classification of Diseases (ICD-10) diagnosis code that represents laterality, if appropriate. 
 
In this case, you billed code 27487-RT, indicating that this service was performed on the patient's right side.  
The medical records confirm that this procedure was performed on the patient's right knee.  However, you have 
billed with a diagnosis code that is appropriate for the left side only. Billed diagnosis code T84.031A is defined 
as "Mechanical loosening of internal left hip prosthetic joint, initial encounter."  As a result, this diagnosis code 
does not match the laterality RT code you billed with procedure 27487. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 27487-RT have not been met. Therefore, we decided that the Plan does not have to pay for 
code 27487-RT billed for date of service December 1, 2022.