Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 19, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 19, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
19, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 19, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 19, 2023, as he 
was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. 
 
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 care from October 19, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 19, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the iTIND system (53899) and cystourethroscopy with 
insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts (C9769). 
 
You asked the Plan to pre-approve the iTIND system and cystourethroscopy. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested treatment is considered 
experimental and therefore is not covered. 
 
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 iTIND system and 
cystourethroscopy. Our reviewer says that the requested iTIND system and cystourethroscopy are not 
considered medically reasonable and necessary in this case. Our physician reviewer found he use of a 
temporarily implanted nitinol device (e.g., iTind) is considered investigational as a treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Further studies are needed to evaluate the durability of 
iTIND outcomes over a longer follow-up, to better define the indications of this approach, and to demonstrate 
the advantages of second-generation device over the first device. iTind is not recommended in the most recent 
AUA Guidelines regarding treatment of BPH. Therefore, the reviewer found that the requested iTIND system 
is not medically reasonable or 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 the iTIND system and cystourethroscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the iTIND system (53899) and cystourethroscopy with 
insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts (C9769).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 billed for date of service April 26, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the codes are valid and payable. The Plan denied 
your request. The Plan says the billed code 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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. We find that CPT code 87900 is not supported in 
the medical record. The results of susceptibility testing are interpreted as S (sensitive), I (intermediate), or R 
(resistant) followed by the minimum inhibitory concentration (MIC) in microgram per milliliter (ug/mL) units. 
These results were not documented in the records. 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 87900 billed for date of service April 26, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Mental 
Health Counselor (MHC) from September 27, 2022, to May 9, 2023. 
 
You asked the Plan to pay for the MHC services. You say that some dates of service were paid. The Plan 
denied your request. The Plan says this provider is not Medicare-eligible. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
In this case, the provider of service is a MHC, which is not a valid provider type to bill Medicare.  Further, 
payment of other claims is not evidence of coverage nor is it a guarantee that all claims will be paid.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MHC services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services provided by a Mental Health Counselor (MHC) from September 27, 2022, to 
May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 19, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 16, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on August 16, 2022, by an out-of-network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 4, 2022, to 
May 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that due to staffing issues related to 
COVID-19, you submitted the NOA late and it was accepted. The Plan denied your request. The Plan says the 
claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 4, 2022, to May 3, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 5, 2023.  
 
You asked the Plan to pay for procedure code 76641. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service July 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that if you do not stay at the facility, you will 
end up back in the hospital. You also say that you need more time at the facility in order to gain back your 
independence. The Plan denied your request. The Plan says this request for a continued admission in a SNF 
does not meet the requirements for approval. 
 
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 continued 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 do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 4, 2021, 
to November 22, 2021. 
 
You asked the Plan to pay for the home health services. You say that the records support the billed HIPPS code 
3GB21. The Plan denied your request. The Plan says the records do not support the billed HIPPS code 3GB21. 
 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 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 home health services. Our reviewer says that the records 
do not support the billed HIPPS code 3GB21. Our reviewer found provided records in this case do not 
document a signed order by a Doctor of Medicine, osteopathy, or podiatry or an allowed practitioner acting 
within the score of his or her state license, certification, or registration for the Physical Therapy billed visit 
November 6, 2021, and the Skilled Nursing billed visit November 22, 2021. Therefore, the records do not 
support the billed Health Insurance Prospective Payment System (HIPPS) code 3GB21. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from November 4, 2021, to November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMs device (33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that this device is medically necessary. 
The Plan denied your request. The Plan says CardioMEMS device at this point should only be approved for 
patients enrolled in a clinical trial. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this 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 the CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the CardioMEMs device (33289, C2624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 18, 2023, billed with 
codes 87150, 87481, 87641, 87653, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 18, 2023, billed with codes 87150, 87481, 87641, 87653, 87798 and 87801.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment, miscellaneous (E1399). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee's current wheelchair is 2 years 
old, and no one will repair it. The enrollee would like a new power wheelchair. The Plan denied your request. 
The Plan says E1399 is not the right code for a power wheelchair. The Plan also says a power wheelchair was 
approved on March 22, 2021; therefore, the enrollee is not eligible for a replacement. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee was approved for a power wheelchair in March 2021. The enrollee is not 
eligible for replacement unless the wheelchair is broken beyond repair. The useful lifetime for durable medical 
equipment is 5 years from the date the item is used. A request for repairs for the wheelchair can be reviewed if 
submitted. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment, 
miscellaneous (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R06.03 has an Excludes1 note in relation to J96.11. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on May 11, 2023.
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 these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is currently receiving medically 
necessary acute 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 the needs for the enrollee do not require the level of care required for LTACH 
transfer. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM sensor. 
 You asked the Plan to pre-approve a CGM sensor. You say that the enrollee is on insulin and will be using 
smart phone as reader. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that the CGM supplies are not covered if they 
will not be used in conjunction with a covered CGM receiver.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a CGM sensor.
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 from June 
12, 2023, to June 13, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment 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 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. Specifically, medical records that are 
clearly marked as pertaining to the date of service at issue have not been provided. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99233 billed for dates of service from June 12, 
2023, to June 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 17 miles for a total of 67 miles. 
 
You asked the Plan to pre-approve additional mileage. The Plan denied your request. The Plan says your 
benefit only allows 50 miles and you have exceeded the benefit limit. This request is not covered by your 
health plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 17 miles for a total of 67 miles.