Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4657, J2501, 90999, and J0604 for date of 
service February 1, 2023, to February 27, 2023. 
 
You asked the Plan to pay for procedure codes A4657, J2501, 90999, and J0604. You say that you disagree 
with the Plan's denial. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A4657, J2501, 90999, and J0604 are not payable as billed. Specifically, End Stage 
Renal Disease (ESRD) services should be billed with AX modifier, alone with the modifier appropriate for the 
route of admission. The documentation does not support that the services were billed correctly. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A4657, J2501, 90999, and J0604 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4657, 
J2501, 90999, and J0604 for date of service February 1, 2023, to February 27, 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 enrollee needs rehabilitation services to regain 
full function again. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
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 that 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rivastigmine. 
 
You asked the Plan to pre-approve Rivastigmine. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rivastigmine.  Benefits for Rivastigmine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 billed for May 15, 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 procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified
probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique.

We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not supported in the medical record. Specifically, a panel of tests was performed and there is a more appropriate singular code for these services. 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 procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 billed for May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control. 
 
You asked the Plan to pre-approve the attendant control. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says records show that the enrollee is able to effectively use 
the beneficiary operated drive control system. The Plan also says that an attendant control is not covered in 
addition to a beneficiary operated drive control system. 
 
The Plan must follow Medicare rules. Medicare rules say that an attendant control is not covered in addition to 
a beneficiary-operated drive control system. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the attendant control have not been met. Therefore, we decided that the Plan does not have to pre-
approve an attendant control.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a washing solution (A9270) provided on March 31, 2023. 
 
You asked the Plan to pay for the washing solution. You say that you would like to appeal the denial as your 
doctor sent a prescription. The Plan denied your request. The Plan says this is not a covered service under your 
benefit plan. 
 
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not 
covered. 
 
We looked at the file and Medicare rules. You asked the Plan to pay for the washing solution as it was 
recommended to you. Based on this information, we decided that Medicare rules for coverage of the washing 
solution have not been met. Therefore, we decided that the Plan does not have to pay for a washing solution 
(A9270) provided on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81433 billed for date of service April 28, 
2023. 
 
You asked the Plan to pay for procedure code 81433. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 81433 is included in payment for code 
81432. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 81433. Our reviewer says that procedure 
code 81433 does not meet criteria for payment. Our reviewer found that Medicare does not allow separate 
payment for multiple methods to test for the same analyte. In the rare circumstance that more than one distinct 
genetic test is medically reasonable and necessary for the same enrollee on the same date of service, the 
provider or supplier must attest that each additional service billed is a distinct procedural service using the 59 
modifier. In this case, support for separate payment 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 procedure code 81433 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81433 billed for date of service April 28, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve continued home health care services. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. The rules also 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. 
 
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 home health services. Our reviewer 
says that the information provided by the Plan does not substantiate their denial reason. Our physician reviewer 
found you have reportedly been receiving home health services. The Plans denied the request for additional 
home health services, stating that you are now able to get up and walk without hands-on help. However, the 
Plan has not provided any records which confirm this statement. There are no records from the home health 
agency or any physical therapy or occupational therapy provider. The case file did not include any evidence 
that the Plan requested these records from the contracted home health provider, who is considered an agent of 
the Plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve continued home health care services.  
 
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 DecisionDx-SCC gene expression testing provided on 
May 8, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC gene expression testing. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-SCC gene expression testing is 
considered non-covered at this time. 
 
We looked at the file and Medicare rules. The services at issue are specifically not covered at this time. Based 
on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC gene expression 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC 
gene expression testing provided on May 8, 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 your doctor says that you will need closer medical 
management of your current medical needs and that your therapist is recommending acute inpatient 
rehabilitation for your recovery. The Plan denied your request. The Plan says the inpatient rehabilitation facility 
(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. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does 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 this enrollee 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: 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 achieve maximum 
level of function. The Plan denied your request. The Plan says the enrollee does not require IRF services to 
regain function.  
 
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 does 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.  
 
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to 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 enrollee is medically stable. There are no acute rehab nursing needs documented. 
Document does not support necessity for admission to an IRF. The complexity of the enrollee's medical, rehab, 
and nursing needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollee's rehab needs can be safely provided in an alternate and low intensity setting 
such as in a skilled nursing 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 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 99239 for date of service February 28, 2023. 
 
You asked the Plan to pay for procedure code 99239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not 
include hospital discharge day management of more than 30 minutes was performed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99239 for date of service February 
28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #30, a pontic 
(D6245) for tooth #29, and retainer crown (D6548) for tooth #28 and #30. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee still has their tooth and would 
like the Plan to pay for the treatment. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because the core buildup, a pontic, and retainer crown are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup (D2950) for tooth #30, a pontic (D6245) for tooth #29, and retainer crown (D6548) for tooth #28 
and #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for golf membership provided from October 1, 2022, to August 
21, 2023. 
 
You asked the Plan to pay for golf membership. You say that you were denied the $400 reimbursement for a 
golf membership purchased in the fall of 2022. The Plan denied your request. The Plan says the benefit limit 
has been exceeded. The Plan also says that you are responsible for the remaining balance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $400 
each year in total for Fitness, Naturopathic Services, Acupuncture, Nutrition/Dietary Education, Weight 
Management Programs, Eyewear and Face Masks. 
 
The Plan's rules for coverage of gym benefits have not been met because The Plan rules say they will 
reimburse up to $400 each year in total for Fitness, Naturopathic Services, Acupuncture, Nutrition/Dietary 
Education, Weight Management Programs, Eyewear and Face Masks. The record shows this benefit has now 
been exhausted. Therefore, we decided that the Plan does not have to pay for golf membership provided from 
October 1, 2022, to August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unoccupied tiedown (K0108). 
 
You asked the Plan to pre-approve an unoccupied tiedown. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says an unoccupied tiedown is not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an unoccupied tiedown (K0108).