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

 
We decided that the Plan has to pay for testing services provided on April 12, 2023, billed with procedure code 
76937-26. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
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 76937-26 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access 
sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular 
needle entry, with permanent recording and reporting (List separately in addition to code for primary 
procedure). 
 
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 testing services provided. Our reviewer says that 
documentation does support the billed code. Our reviewer found that the documentation specifically details 
ultrasound guided percutaneous access, so 76937-26 is justified. 
 
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 testing services provided have been met. Therefore, we decided that the Plan 
has to pay for testing services provided on April 12, 2023, billed with procedure code 76937-26.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 24, 2023, 
through January 26, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the emergency department (ED) evaluation revealed atrial fibrillation with rapid ventricular 
response. The enrollee was treated in the ED; admitted and evaluated by Cardiology. His condition stabilized 
and improved with medical therapy and he was discharged home when considered medically stable on  
January 26, 2023. The review has determined that the record showed that at the time of the inpatient admission 
the admitting physician reasonably expected that the enrollees necessary hospital care (including earlier ED 
and/or observation care) would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from January 24, 2023, through January 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of in-home support services. 
 
You asked the Plan to pre-approve additional hours of in-home support services. You say that you need 
additional hours of services due to being visually impaired. You need continued assistance with everyday 
activities. The Plan denied your request. The Plan says you have exhausted your benefit for services. 
 
The Plan must follow Medicare rules. Medicare rules say that members receive up to 60 hours per year of in-
home support services including light house help, companionship services, grocery shopping, technology 
lessons, and social transportation. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional hours of in-home support services have not been met. The records show that you have 
used 60.25 hours of in-home support services. The EOC confirms you receive up to 60 hours per year of in-
home services, therefore, you have exhausted your benefit with the plan. Therefore, we decided that the Plan 
does not have to pre-approve additional hours of in-home support services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for 11 units of code 87798 billed for date of service March 2, 2023. 
 
You asked the Plan to pay for 11 units of code 87798. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says that this code is not supported in the records 
provided for the number of units 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 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 11 units of code 87798. Our reviewer says that these services 
are supported. Our reviewer found the documentation supports 11 units of code 87798. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 11 units of code 87798 have been met. Therefore, we decided that the Plan has 
to pay for 11 units of code 87798 billed for date of service March 2, 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 the services (00560, 36620, 99100) provided on March 1, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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.  
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 use of codes 00560 
and 36620 is not supported by the records provided. Our reviewer found that review of the medical records 
submitted does not reveal sufficient documentation to use either of these codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 00560 and 36620 have not been met. 
 
We also find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (00560, 36620, 99100) provided on March 1, 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 you need admission to an inpatient rehabilitation 
facility to be appropriately monitored and rehabilitated as you are now essentially now wheelchair bound 
and/or walker bound from severe global weakness and profound fatigue of unknown etiology 
and prognosis. The Plan denied your request. The Plan says your records do not show that you have complex 
rehabilitation needs that require frequent evaluation by a rehabilitation physician. The Plan says that the 
services needed may be provided safely in a lower level of 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that all the physicians are requesting you to have 
extensive care, lower level of care will not cover your needs. The Plan denied your request. The Plan says your 
records do not show you need an intensive team for your care. The Plan says that the services needed may be 
provided safely in a lower level of 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.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 April 19, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic testing provided on November 16, 2022. 
 
You asked the Plan to pay for the lab testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that you are out of network. 
 
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 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. The plan follows these rules. 
 
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 provider was in-network or out-
of-network with the Plan. The documentation submitted 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 diagnostic testing provided on 
November 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 22, 2023, to 
February 27, 2023. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found due to the enrollee's co-morbidities and acute medical issues, an inpatient stay 
anticipated for more than two midnights was 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 the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from February 22, 2023, to February 27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Enteral Nutrition. 
 
You asked the Plan to pre-approve the Enteral Nutrition.. You say that the item is medically necessary. The 
Plan denied your request. The Plan says you do not have a condition that interferes with swallowing and are 
able to eat or drink by mouth. In addition, you do not have a condition that prevents normal digestion. 
 
The Plan must follow Medicare rules. The rules say that Enteral nutrition is covered for a beneficiary who 
requires feedings via an enteral access device to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's overall health status and has a permanent: 
A. full or partial non-function or disease of the structures that normally permit food to reach the small bowel; 
OR, 
B. disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small bowel. 
Adequate nutrition must not be possible by dietary adjustment and/or oral supplement 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve the Enteral Nutrition.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 11, 2022, to 
January 5, 2023.  
You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. 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 November 11, 2022. The NOA was not received by the Plan until January 
24, 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 December 11, 2022, to January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 2, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20611 & J7318 provided on May 9, 2023. 
 
You asked the Plan to pay for procedure codes 20611 & J7318. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 20611, & J7318 are not supported in the medical record. Specifically, the records 
didn't include documentation of permanently recorded images to support code 20611. The number of units of 
J7318 billed are not supported. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 20611 & J7318 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 20611 & J7318 provided on May 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lower 
extremity (73700) for computer-assisted musculoskeletal surgical navigation planning. 
 
You asked the Plan to pre-approve a CT scan of the lower extremity for computer-assisted musculoskeletal 
surgical navigation planning. You say that this is medically necessary. The Plan denied your request. The Plan 
says since the computer-assisted components of a MAKOplasty knee replacement are considered 
investigational, any planning CT scans needed to perform the MAKOplasty are also considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the lower extremity for 
computer-assisted musculoskeletal surgical navigation planning. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found no large volume, long-term/high-quality clinical studies 
fully confirm clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-
assisted surgery over standard surgical approaches in total knee arthroplasty. As the procedure itself is not 
supported, this request is not supported.  
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 CT scan of the lower extremity for computer-assisted musculoskeletal surgical 
navigation planning have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
computed tomography (CT) scan of the lower extremity (73700) for computer-assisted musculoskeletal 
surgical navigation planning.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the respite care provided from February 
1, 2023, to March 1, 2023. 
 
You asked the Plan to provide reimbursement for the respite care. The Plan denied your request. The Plan says 
you were not enrolled in hospice care. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that short-term respite care is only covered under the hospice care benefit. 
 
We looked at the file and Medicare rules. The record shows that you were not enrolled in hospice during the 
time the respite care was provided. Therefore, we decided that the Plan does not have to provide reimbursement 
for the respite care provided from February 1, 2023, to March 1, 2023.