Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97530, and 97750 for date of service 
March 15, 2023. 
 You asked the Plan to pay for procedure codes 97110, 97530, and 97750. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services 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 97110, 97530, and 97750 are not supported in the medical record. Specifically, the 
medical records submitted document a total time for the therapy session; however, the records do not document 
the time spent performing the therapeutic procedures. This means codes 97110 and 97530 are not supported.  
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 97550 
is a column II code to column I code 97530. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on this information, we decided that Medicare rules for coverage of procedure codes 
97110, 97530, and 97750 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 97110, 97530, and 97750 for date of service March 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service January 17, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
 
 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 procedure code 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented with abdominal 
pain in the left lower quadrant that was moderate in intensity, that was thought to be potential diverticulitis. 
The documentation supports an appropriate exam, but not an appropriate history or medical decision making of 
high level. Therefore, code 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service January 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 enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for IRF care. 
 
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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at 
an intensive rehabilitation therapy program. Medically necessary care can be provided for the enrollee in 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service November 3, 
2022, to December 2, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 4, 2022. The NOA was not received by the Plan until January 18, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service November 3, 2022, to December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and are unable to perform daily 
activities on your own. You say that the requested IRF services are necessary for you to build your strength so 
you can return home and not get hurt. The Plan denied your request. The Plan says you do not meet Medicare 
guidelines for services in 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service March 7, 
2023.  You asked the Plan to pay for procedure code 88305. You say that medical records were provided. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88305 is 16. The MAI value for this code is 3. You billed 17 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were correctly coded and 
were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88305 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
88305 billed for date of service March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service August 30, 
2022. 
 You asked the Plan to pay for procedure code 88342. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 88342 is bundled into payment for code 88189. 
 
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 code 88342 
is a column II code to column I code 88189. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88342 billed for date of service August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk more than ten steps and 
require IRF services to regain your prior level of functioning. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for IRF admission. 
 
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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF as 
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 01402 for date of service July 26, 2022. 
 
You asked the Plan to pay for procedure code 01402. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 126 units of CPT code 01402 are not supported in the medical record. When a block is placed 
before induction or after emergence, the time spent placing the block should not be added to the reported 
anesthesia time. Based on this information, we decided that Medicare rules for coverage of procedure code 
01402 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 01402 
for date of service July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Arrhythmia and Cardiomyopathy Comprehensive 
Panel and Add-on Preliminary-evidence Genes for Arrhythmia and Cardiomyopathy provided on March 2, 
2023, and billed with codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, and 81400. 
 
You asked the Plan to pay for the Invitae Arrhythmia and Cardiomyopathy Comprehensive Panel and Add-on 
Preliminary-evidence Genes for Arrhythmia and Cardiomyopathy. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing was not billed with a single panel code. 
 The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Invitae Arrhythmia and 
Cardiomyopathy Comprehensive Panel and Add-on Preliminary-evidence Genes for Arrhythmia and 
Cardiomyopathy  have not been met. Therefore, we decided that the Plan does not have to pay for the Invitae 
Arrhythmia and Cardiomyopathy Comprehensive Panel and Add-on Preliminary-evidence Genes for 
Arrhythmia and Cardiomyopathy provided on March 2, 2023, and billed with codes 81408, 81407, 81406, 
81161, 81405, 81404, 81403, and 81400.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (G0482) provided on December 8, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this claim is missing information required to 
process payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that effective January 1, 2011, for claims processed on or after January 1, 2011, submission of the 
location where the service was rendered (item 32) will be required for all Place of Service (POS) codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, item 32 is blank on this claim. Therefore, we 
decided that the Plan does not have to pay for laboratory services (G0482) provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an infectious disease doctor at 
tertiary level provider. 
 
You asked the Plan to pre-approve a specialist visit at a tertiary facility. You say that you have been seeing this 
provider since February 2023. You say that you have been seeing other tertiary providers at this facility since 
July 2022. You say that you have a very serious bone infection since your first knee replacement surgery. You 
also say that this is medically necessary. The Plan denied your request. The Plan says the documentation 
provided does not support the need for care with a highly specialized tertiary care provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 pre-approve a specialist visit at a tertiary facility. 
Our reviewer says that the request to see an infectious disease doctor at tertiary level is not medically 
necessary. Our physician reviewer found that you had an office visit with an infectious disease doctor at 
tertiary level provider on June 30, 2023, following a recent left knee surgery following being started on 
intravenous (IV) antibiotics and required seeing an outpatient infectious disease doctor to help transition him to 
oral antibiotics. The reviewer found that this could be addressed by an in-network doctor. The reviewer found 
there was nothing in the provided documentation that described your situation as unique or in a special 
circumstance that would require the out-of-network infectious doctor. The reviewer also found that the Plan 
provided an appropriate provider for the patient to see for this follow-up that meets the standards of care for 
treatment. Therefore, the reviewer found that the requested specialist visit at a tertiary level is 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 a specialist visit at a tertiary facility have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an office visit with an infectious disease doctor at tertiary level 
provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the BOA system (L5999). 
 
You asked the Plan to pre-approve the BOA system. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 BOA system. Our reviewer says 
that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical record fully establishes the reasonableness and medical necessity of this item. 
 
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 BOA system have been met. Therefore, we decided that the Plan has to pre-
approve the BOA system (L5999).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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 a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF genetic liquid biopsy (81455) provided 
March 1, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says the genetic 
panel described as Tempus xF requested does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus xF genetic liquid biopsy (81455) provided March 
1, 2023.