Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 11, 2022, to 
May 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA is on file with the Plan. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 11, 2022, to May 
10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the PT services with an OON provider. You say that the services are 
medically necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service December 6, 2022. 
 
You asked the Plan to pay for code 99285. You say that these services were medically necessary. The Plan 
denied your request. The Plan says billed code 99285 is not supported in the medical record. As a result, this 
claim was down-coded to 99284 to reflect the services provided. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the enrollee was a then, 66 year-old male who presented 
to the emergency room with dysuria, urgency and decreased urine flow. He had been treated with antibiotics 2 
weeks prior for a urinary tract infection. The evaluation revealed urinary retention with Bladder scan with 
greater than 500ml after voiding x 2. A Foley catheter was placed and the enrollee was discharged home with 
urology follow-up. The review has determined that the documentation did not support procedure code 99285. 
Specifically there was no medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service December 6, 2022.
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 will benefit from acute rehab optimize 
functioning level. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
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. While the 
medical record supports a need for physical 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. 
 
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 procedure code 81551 billed with diagnosis codes D29.1 and 
N40.1 provided on February 9, 2023. 
 
You asked the Plan to pay for procedure code 81551. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes D29.1 and N40.1 should not be reported together. Therefore, we decided that the Plan does not 
have to pay for procedure code 81551 billed with diagnosis codes D29.1 and N40.1 provided on February 9, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device and implantation. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that his device is indicated for wirelessly 
measuring and monitoring pulmonary artery pressure and heart rate in New York Heart Association Class III 
heart failure patients who have been hospitalized for heart failure in the previous year. You also say that the 
hemodynamic data are used by physicians for heart failure management and with the goal of reducing heart 
failure hospitalizations. The Plan denied your request. The Plan says the requested device 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 a CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested device 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device and implantation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 15, 
2023.  
 
You asked the Plan to pay for procedure code 99458. You say that you disagree with the denial. 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 99458 is 3. The MAI value for this code is 3. You billed 11 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 14, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory 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 laboratory services provided on September 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from December 3, 2022, to December 4, 
2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that rules for payment for home health services have not been met. 
 
The Plan must follow Medicare rules. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial indicates that the claim for the services at issue 
was submitted with an incorrect bill type. However, the incorrectly coded claim was not included in the case 
record. It is the Plan's responsibility to support its denial with evidence. In this case, the Plan's denial is not 
supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for home health 
services provided from December 3, 2022, to December 4, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 15, 2022, 
to December 14, 2022. 
 You asked the Plan to pay for the home health services. 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 15, 2022. The NOA was not received by the Plan until 
December 20, 2022. 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 provided from November 15, 2022, to December 14, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for hospital outpatient clinic visit, for specimen collection for severe acute 
respiratory syndrome coronavirus 2 (SARS-COV-2), or COVID-19 (C9803) provided December 26, 2022. 
 
You asked the Plan to pay for the outpatient visit. You say that you received a zero explanation of benefits. 
You are requesting reconsideration of the claim in order to pay according to expected reimbursement. The Plan 
denied your request. The Plan says that charges exceed fee schedule/maximum allowable or 
contracted/legislated fee arrangement. 
 
The Plan must follow Medicare rules. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided any records or any information to substantiate their 
reason to continue to deny payment. Therefore, we decided that the Plan has to pay for hospital outpatient 
clinic visit, for specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), or 
COVID-19 (C9803) provided December 26, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device (0266T, C1825).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care billed with code 99232 for 
February 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care billed with code 99232 for February 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 88304 and 88311 on 
June 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 28, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services billed with codes 88304 and 88311 on 
June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee will end up back in the hospital 
if she does not get the requested ventilator.  The Plan denied your request. The Plan says the records do not 
show that the enrollee has been diagnosed with a disease that would support coverage of a home mechanical 
ventilator.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
enrollee reportedly has chronic respiratory failure from chronic obstructive pulmonary disease.  The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine 
with average volume assured pressure support (AVAPS) capability and failure of such a device has not been 
documented.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.