Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 28, 
2021, to December 3, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records provide clear supportive evidence of metabolic encephalopathy. You say that G93.41 is a valid 
diagnosis and DRG 124 is accurate. The Plan denied your request. The Plan says diagnosis code G93.41 is not 
supported, which resulted in a DRG change. 
 
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 with diagnosis code G93.41, defined as metabolic encephalopathy. 
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 diagnosis code G93.41 is not supported. Our physician reviewer found 
the enrollee presented to the hospital with shingles and failure to thrive. The enrollee was also diagnosed with a 
urinary tract infection and was started on antibiotics and antivirals. There was no change in mental status 
following treatment and the enrollee was noted to likely be at baseline with neurological symptoms related to 
chronic dementia. Therefore, there is insufficient support made for using diagnosis code G93.41.   
 
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 provided from November 28, 2021, to December 3, 2021, at the DRG originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 5 additional units of evaluation and management services 
(G2212) provided on October 6, 2022. 
 
You asked the Plan to pay for additional units of evaluation and management services. You say that the number 
of units billed was medically necessary. 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 G2212 is 6. The MAI value for this code is 3. You billed 11 units of this 
code, exceeding the MUE. 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 additional units of 
evaluation and management services. Our reviewer says that additional units of evaluation and management 
services do not meet criteria for payment. Our physician reviewer found that the provided documentation does 
not reflect the medical necessity of 5 additional units billed over and above the MUE of 6 units. 
 
We looked at this physician's review, the file, and Medicare rules. You did not provide all the required 
evidence showing that the excess units were medically necessary. Based on this information, we decided that 
Medicare rules for coverage of additional units of evaluation and management services have not been met. 
Therefore, we decided that the Plan does not have to pay for 5 additional units of evaluation and management 
services (G2212) provided on October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing (81479) provided on April 6, 2022.  
 
You asked the Plan to pay for the GeneSight testing. You say that this test is covered by Medicare. The Plan 
denied your request. The Plan says this testing was not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met.  
 
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 GeneSight testing. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the provided documentation lists 
the enrollees failed medications, which included Lexapro (escitalopram), Zoloft (sertraline), Klonopin 
(clonazepam), Lamictal (lamotrigine), and Effexor (venlafaxine). Though the order stated that Viibryid 
(vilazodone), Trintellix (vortioxetine), Cymbalta (duloxetine), and Elavil (amitriptyline)were being considered 
for augmentation or starting/switching to, there is no documentation of such provided in the medical record. 
There is no documentation in the clinical record that the provider has already considered non-genetic factors to 
make a preliminary drug selection. There is no documentation that the clinician has made an initial 
personalized decision for the enrollee based on the criteria listed in the LCD. The review has determined that 
the records did not support that the enrollee met the criteria in LCD L38394 for the testing. The services are not 
reasonable and 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 GeneSight testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the GeneSight testing (81479) provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
enrollee's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro Motion G orthosis.
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 the rehab in order to get around 
the house without assistance. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 23, 
2023, to February 26, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says inpatient level of care is not supported. 
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented with a headache, but without an exam or signs that would 
warrant an expectation of inpatient hospitalization for more than 2 days. Thus, the inpatient status was not 
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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 23, 2023, to February 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation code A0425 billed for date of 
service November 16, 2022. 
 You asked the Plan to pay for the billed services. You say that it was in the enrollee's best interest to be 
transported to the nearest facility. 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 providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 411 units on 
one claim line, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
transportation code A0425 billed for date of service November 16, 2022.
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee continued stay at acute hospital until the enrollee is stable 
enough for discharge to a lower level of care has not been denied.  
 
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 the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until more stable for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary 
as it would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder triage test (81479) provided on October 26, 
2022.  
 
You asked the Plan to pay for the CXbladder triage test. You say that the evidence supporting use of Cxbladder 
Triage test as a medically necessary diagnostic service is well established.  The Plan denied your request. The 
Plan says the CXbladder panel remains unproven at this time.  
 
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 CXbladder triage test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this test does not have sufficient current high-quality evidence to support its 
efficacy on improving overall outcomes compared to current testing standards to support the use for this 
enrollees case. This test has a lower specificity than urinary cytology. Therefore, this request for CXbladder 
test will be considered not medically necessary at this time.  
 
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 CXbladder triage test have not been met. Therefore, we decided that the 
Plan does not have to pay for the CXbladder triage test (81479) provided on October 26, 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 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. 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 29, 2023, to February 25, 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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for weakness and a fall. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. 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. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870 billed for date of service July 27, 
2020. 
 You asked the Plan to pay for procedure code 95870. The Plan denied your request. The Plan says payment for 
code 95870 is bundled into payment for code 95868. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95870 
is a column II code to column I code 95868. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 95870 billed for date of service July 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee keeps being sent to a physical 
therapist who does not perform the physical therapy they need. The Plan denied your request. The Plan says 
that physical therapy is available in network. 
 
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 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 genicular nerve ablation provided on February 15, 2023. 
 
You asked the Plan to pay for genicular nerve ablation. You say that this was medically necessary. The Plan 
denied your request. The Plan says the diagnosis is not supported. 
 
  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 genicular nerve ablation. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is the subject of ongoing clinical trials and is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pay for genicular nerve ablation provided on February 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast. 
 
You asked the Plan to pre-approve Reclast. You say that Reclast is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for Reclast. 
  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 Reclast. Our reviewer says that the 
requested service is not recommended. Our physician reviewer found the enrollee has osteoporosis. However, 
the records provided are insufficient to establish that the elements of the coverage criteria are satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Reclast.