Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the visits. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the additional visits are not medically necessary. 
 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 visits. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the additional requested therapy is not generally accepted as specific and effective therapy for the 
enrollees condition beyond what was approved by the health plan. The records do not demonstrate that 
the unique skills of a professional therapist are required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program and  the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the enrollee's current condition or to prevent or slow further deterioration. The enrollee has had extensive 
physical therapy instruction and is compliant in a home exercise program. The requested additional therapy 
sessions are 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on September 25, 2022, billed with 
evaluation and management (EM) code 99233. 
 
You asked the Plan to pay for the inpatient hospital services provided. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says that payment for this service is bundled into 
payment of another service. 
 
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. We find that the specific denial rationale offered by the Plan is not supported. 
The Plan says that payment for code 99233 is bundled into payment for code 99223. The Plan has not provided 
an explanation of benefits showing that code 99223 was paid on this date of service. As such, the denial of this 
service is not substantiated. Therefore, we decided that the Plan has to pay for inpatient hospital services 
provided on September 25, 2022, billed with evaluation and management (EM) code 99233.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on September 3, 2022, to 
December 13,2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the acupuncture services. You say that acupuncture is a benefit that you can 
receive. You think these expenses should be covered because they were covered before. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 the acupuncture services provided on September 
3, 2022, to December 13,2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 8, 2021, 
to January 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that claims for home health services must be billed with correct 
data elements. 
 
We reviewed the file and the Medicare rules. We find that the home health claims must be billed with the first 
date of service of Q5001 through Q5009 in order to have any other date of service use Q5001 through Q5009. These codes must be also billed with revenue codes. The claim was submitted without the first date of service 
being properly billed. 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 December 8, 2021, to January 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 You asked the Plan to pre-approve continued SNF care. You say that continued SNF care is essential in 
providing the skilled nursing, physical and speech therapy to regain a measurable quality of life. The Plan 
denied your request. The Plan says continued SNF care is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC).  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show an inability to take long-term anticoagulation. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical necessity of implanting a LAAC device in this enrollee in whom there is 
elevated risk of thromboembolic stroke due to atrial fibrillation and high CHADS2VASC score. There is no 
contraindication to anticoagulation according to the physician. As such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollee's 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous left atrial appendage closure (LAAC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service September 8, 
2022.  You asked the Plan to pay for procedure code 88341. You say that these services were necessary and are 
supported in the medical record. 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 88341 is 13. The MAI value for this code is 3. You billed 16 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service September 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service December 
13, 2022. 
 You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99220. 
 
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 99284 
is a column II code to column I code 99220. 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 99284 billed for date of service December 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service January 1, 2023. 
 
You asked the Plan to pay for procedure code 99233. 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. 
 
We looked at the file and Medicare rules. Review of the file shows that surgery procedure 27197 was provided 
on the same date of service. Code 27197 has a global surgery value of 0 days. Code 99233 was billed within 
the global surgery period of procedure 27197 without an appropriate modifier. This means code 99233 is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99233 for date of service January 1, 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 meets full inpatient acute rehabilitation 
criteria. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as an assisted living facility with home health services. 
 
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 has a past medical history of hypertension, congestive heart failure, 
osteoarthritis and neuralgia and is living in an assisted living facility with weakness and functional decline. The 
enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. 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.  
 
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 lab services (81226, 81240, 81241, 81306, 81328, 81335, 
81227, 81225, 81231, 81232) provided on December 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one CPT code must be submitted for the panel 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single testing panel. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81226, 81240, 81241, 81306, 81328, 
81335, 81227, 81225, 81231, 81232) provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve exclusion of left atrial appendage (LAA), open, any method (eg, 
excision, isolation via stapling, oversewing, ligation, plication, clip). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a review of the medical literature has not found this device to be safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the appropriateness and medical necessity of LAA ligation at time of coronary artery 
bypass grafting (CABG) surgery in this patient with a history of atrial fibrillation and chronic anticoagulation. 
This is not a stand-alone procedure but is instead planned to be carried out at the time of cardiac surgery. As 
such, it would appear that LAA ligation is reasonable in this enrollee. 
 
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 pre-
approve exclusion of left atrial appendage (LAA), open, any method (eg, excision, isolation via stapling, 
oversewing, ligation, plication, clip).  
 
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 procedure code 88341 billed for date of service February 15, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that these services were necessary and are 
supported in the medical record. 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 88341 is 13. The MAI value for this code is 3. You billed 20 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 24, 2023, to 
January 27, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that home health services must be billed with appropriate type 
of bill. 
 
We reviewed the file and the Medicare rules. Review of the file shows that the claim was billed with an invalid 
type of bill for this home health provider. As the claim was not billed with a correct type of bill, no payment 
can be made on this claim. 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 January 24, 2023, to January 27, 2023.
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 you are requesting coverage for the home 
ventilator with AVAPS-AE as opposed to a simpler bi-level device with backup rate and AVAPS mode due to 
bi-level devices, include BiPAP devices with AVAPS, being extremely flow capability limited. The requested 
device can provide a higher flow to satiate air hunger. You say that patients with end stage COPD and air 
hunger demand much higher flow levels than a simple bi-level device is capable of providing. You say that air 
trapping is already present for the enrollee and the requested device is equipped with synchrony assurance 
features and prevents air trapping. You say that additional air trapping would be detrimental and potentially life 
threatening to the enrollee's condition.  The Plan denied your request. The Plan says home mechanical 
ventilators set in average volume-assured pressure support (AVAPS) mode with Auto- expiratory positive 
airway pressure (AE) that could be delivered by bi-level positive airway pressure (BiPAP) is not covered.   
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 provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. Provided medical records do not include documentation of the need for mouthpiece ventilation. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test (81528). 
 
You asked the Plan to pre-approve a Cologuard test. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested test is covered once every three 
years. 
 
The Plan must follow Medicare rules. Medicare rules say that a Cologuard test is covered once every three 
years.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cologuard test have not been met. The records show that you had a Cologuard test in June 2022. 
NCD 210.3 confirms that you are covered for the Cologuard test once every three years, therefore, you do not 
meet criteria for the requested test. Therefore, we decided that the Plan does not have to pre-approve a 
Cologuard test (81528).