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

 
We decided that the Plan has to pay for 99152. We decided that the Plan does not have to pay for 76937.  
 
You asked the Plan to pay for the medical services (76937-GC and 99152-GC) provided January 31, 2023.. 
You say that the claim should be paid. The Plan says that the services are not supported by the records. 
 
 
 
 We decided that the Plan has to pay for 99152.  
 
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 services. Our reviewer says that the 
documentation does support 99152. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
99152.  
 
We also decided that the Plan does not have to pay for 76937. 
 
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 76937. Our reviewer says that the 
documentation does not support 76937. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 76937 have not been met. Therefore, we decided that the Plan does not have to 
pay for 76937. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481) provided April 21, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the drug testing have been met. 
Review of the file shows an unsigned requisition and there is a lack of documentation as to why the testing was 
ordered. Therefore, we decided that the Plan does not have to pay for the drug testing (G0481) provided April 
21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary to solve the enrollee's chronic low back pain. The Plan denied your request. The Plan says this 
enrollee does not meet evidence-based criteria. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes 
without facet degenerative joint disease or stenosis. The cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital admission/care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show the enrollee does not have hemodynamic instability or 
neurologic abnormalities or need for inpatient monitoring. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission is 
met in this case. Our physician reviewer found the records do not indicate at the time of admission that the 
enrollee was expected to require a two-midnight admission. There was no documentation of medical 
intervention, and the reported diagnosis is for weakness with need for placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital admission/care.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the requested physical therapy is 
generally accepted as a specific and effective therapy for lower extremity wounds secondary to venous stasis. 
The enrollee is noted to have venous stasis wounds of the bilateral lower extremities and is receiving wound 
care with debridement and application of Triad, foam and compression wrapping. Measurements of the 
enrollees wounds are provided to track objective improvement with therapy. Therefore, the 10 visits of 
additional physical therapy are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve 10 additional physical therapy visits.  
 
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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does not 
support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain their functional status.  The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 the enrollee needs this care to regain strength and 
mobility. The Plan denied your request. The Plan says the enrollee's medical condition does not require IRF 
services, and care can be provided in another setting.  
 
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 enrollees 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve a PET scan. You say that the service is needed due to your recent prostate 
cancer diagnosis. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
requested PET scan is not reasonable and necessary. Our physician reviewer found initial anti-tumor treatment 
strategy in Medicare beneficiaries who have adenocarcinoma of the prostate is not covered. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glucose monitor supplies (A4239) provided on May 30, 
2023. 
 
You asked the Plan to pay for glucose monitor supplies. You say that this was billed on a different date of 
service and should be paid. The Plan denied your request. The Plan says only one unit is payable every 30 days. 
 
The Plan must follow Medicare rules. Medicare rules say that billing more than one (1) UOS per thirty (30) 
days of code A4238 or A4239 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The record shows that code A4239 was previously paid for date of 
service May 17, 2023, fewer than 30 days prior to the date of service at issue. Based on this information, we 
decided that Medicare rules for coverage of glucose monitor supplies have not been met. Therefore, we decided 
that the Plan does not have to pay for glucose monitor supplies (A4239) provided on May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 2, 2023, billed with 
codes 81162-90, 81201-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 81351- 90, 81209-
90, 81314-90, 81334-90, 81345-90, and 81272-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 2, 2023, billed with codes 81162-90, 81201-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 
81321-90, 81351- 90, 81209-90, 81314-90, 81334-90, 81345-90, and 81272-90.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on October 11, 2022, billed 
with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661 and 
87798. 
 
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 October 11, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 
87563, 87591, 87641, 87651, 87653, 87661 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73140 and 12001 provided on April 29, 
2023. 
 
You asked the Plan to pay for procedure codes 73140 and 12001. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed codes are not separately payable. 
 
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 73140 and 12001 are not supported in the medical record. Specifically, these codes 
have a status indicator of Q1 according to Addendum B - OPPS Payment by HCPCS Code for 2023. These 
codes were billed on the same date of service as code 99284 which has a status indicator of "V". Based on this 
information, we decided that Medicare rules for coverage of procedure codes 73140 and 12001 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 73140 and 12001 provided 
on April 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27788 rendered on April 29, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 27788-54-RT remains 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 27788 is "Closed treatment of distal fibular fracture 
(lateral malleolus); with manipulation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that CPT 27788: closed treatment of distal fibular fracture (lateral malleolus); with manipulation was rendered in this case.  The enrollee was placed in an ankle stirrup splint with Ortho-Glass without 
manipulation. However, this procedure was noted to have been performed without manipulation. 
 
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 procedure code 27788 rendered on April 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barrett's esophagus assay (0108U) 
provided on April 11, 2023. 
 
You asked the Plan to pay for the TissueCypher Barrett's esophagus assay. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this assay for determining the risk of cancer 
remains unproven in the setting of Barrett's esophagitis. 
 
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 pay for the TissueCypher Barrett's esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that there is insufficient evidence that TissueCypher Barrett's 
esophagus assay testing impacts management and outcomes of patients with Barrett's esophagus without 
dysplasia 
 
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 TissueCypher Barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barrett's esophagus assay (0108U) provided on 
April 11, 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 stay is medically necessary. The Plan denied 
your request. The Plan says the enrollee's medical condition is stable and does not need medical monitoring 
from a rehabilitation physician. The Plan says services may be provided at 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 enrollee is functioning at a level of rehabilitation need routinely managed in a 
post-acute setting other than an IRF because persons deconditioned following an acute illness at his level of 
function do not require intensive or complex rehabilitation services and do not require frequent physiatry 
oversight or evaluation.  
 
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 provided from March 12, 2023, to 
April 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
timely. 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 March 12, 2023, to April 
10, 2023.