Persius/hicric huggingface dataset:
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 you are still not able to walk well and are still very 
weak. You say you need more time because you have not progressed the way you should. The Plan denied your 
request. The Plan says the request for continued admission in a SNF 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 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. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 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 the services provided on November 22, 2022, and November 
23, 2022. 
 
You asked the Plan to pay for the services. 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 effective for claims with dates of service July 1, 
2007, and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE. This integration will result in the routing of all institutional outpatient claims, 
including non-OPPS hospital claims, through a single integrated OCE.  
 
We looked at the file and Medicare rules. In this case, the outpatient claim was billed with code 11005, which is an inpatient only procedure. As such, the claim returned OCE Edit 18, which causes all other line items on 
the same day to be denied with Edit 49. The claim is not payable as billed. 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 the services provided on November 22, 2022, and November 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee has 
upcoming appointments, and she needs additional transportation. The Plan denied your request. The Plan says 
the enrollee has used 24 transportation trips. The enrollee has exceeded her benefit limit. 
 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 24 trips per year.  
 
We looked at the request, the records in the case file, and the rules. Based on this information, we decided that 
the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1, 
2007, and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE.  
 
We looked at the file and Medicare rules. In this case, the claim returned OCE Edit 88. which denies the claim. 
This occurred because code 0054A was reported on the Federal Qualified Health Centers (FQHC) claim, and 
was reported without condition code 65. As such, the claim is subject to be processed under the FQHC PPS, 
but there was no required FQHC payment code reported. 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 the services provided on April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50715 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 50715. You say that you have correctly billed the service at 
issue. The Plan denied your request. The Plan says the provided records do not support the service 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 50715 is: Ureterolysis, with or without repositioning of 
ureter for retroperitoneal fibrosis. 
 
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 50715. Our reviewer says that procedure 
code 50715 does not meet criteria for payment. Our reviewer found that the medical record does not support CPT code 50715. Lysis, when performed as part of the surgical approach, is not separately reportable. The 
record does not contain evidence of the presence of adhesions that required a significant amount of separate 
work that would be separately reportable. 
 
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 50715 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 50715 billed for date of service October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment delivery, superficial and/or ortho 
voltage (77401). 
 
You asked the Plan to pre-approve the outpatient service. You say that this is a life-threatening matter. You say 
that your dermatologist approved this treatment. You also say that this is medically necessary.  The Plan denied 
your request. The Plan says the requested treatment is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the outpatient service. Our reviewer 
says that the requested radiation treatment delivery is not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the provided documentation does not indicate any compelling reasons 
offered for why superficial radiation (SRT) would be needed over more standard approaches of radiation delivery. Therefore, the reviewer found that the requested service 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 outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiation treatment delivery, superficial and/or ortho voltage (77401).
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 are requesting reconsideration for the denial of 
an IRF admission. You say the enrollee hopes to return to their prior level of function in the shortest amount of 
time through intensive inpatient rehabilitation. The Plan denied your request. The Plan says it is not medically 
necessary for the enrollee to be admitted into an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from May 26, 2023, forward. 
 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 do not require skilled nursing or therapy services on a daily basis. You do not 
meet severity of illness or intensity of service criteria for an inpatient basis in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care from May 26, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on August 9, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit and related services. You say that this was medically necessary. 
The Plan denied your request. The Plan says this was not authorized.  
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and related services provided on 
August 9, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liposuction of left chest. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered cosmetic. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that based on the medical records provided there is no documentation that the procedure (liposuction of 
left chest, suction assisted removal of fat of body) at issue in this case meets all Medicare criteria being 
reasonable and necessary. The provided records in this case do not clarify that the procedure would be 
furnished in accordance with accepted standards of medical practice.  
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve liposuction of left chest.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the enrollee falls within the range of osteopenia at the 
left femoral neck and the left total hip. The documentation does not support that the Prolia is medically 
reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service January 9, 
2023.  
 
You asked the Plan to pay for procedure code 64447. You say that two different types of nerve blocks were 
performed. 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 64447 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation did not show that the excess units were correctly coded and 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
64447 have not been met.  Therefore, we decided that the Plan does not have to pay for procedure code 64447 
billed for date of service January 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes 
A41.01 and A41.52 rendered from September 30, 2021, to October 5, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of the DRG adjustment. The Plan denied your request. 
The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes A41.01 and A41.52. 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the enrollee presented with general malaise and developed a fever in the 
emergency department. The enrollee was ultimately treated for a foot wound and cellulitis. There is no 
evidence of hypotension, hypoperfusion or organ failure. As such, a diagnosis of sepsis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis codes A41.01 and A41.52 rendered from September 30, 
2021, to October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36470 billed for date of service September 
14, 2022.  
 You asked the Plan to pay for procedure code 36470. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 36470 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 36470 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 36470 billed for date of service September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on October 14, 
2022. 
 
You asked the Plan to pay for the services. 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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed". 
 
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 code G0482 is 
not supported by the records provided. Our reviewer found that the medical records provided do not include 
sufficient documentation to validate that G0482 was performed on October 14, 2022, therefore this procedure 
cannot be verified. 
 
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 the drug testing services (G0482) provided on October 14, 2022.
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 an in-network doctor. 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.