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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a LTACH 
admission for their wound care and antibiotics management. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the following requirements 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 pre-approve an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found three months have 
not elapsed since the last ESI, and the enrollee has not had at least three months of relief with the previous 
injection. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 13, 2023, to 
April 20, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely filed the NOA. 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 13, 2023, to April 
20, 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 is below baseline level of function with 
ongoing therapy needs and complex medical conditions that require daily physician visits. The Plan denied 
your request. The Plan says the enrollee's condition does not meet the requirements for an IRF admission.  
 
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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Intravenous Insulin Therapy (OIVIT) services provided 
on February 27, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Intravenous Insulin Therapy (OIVIT) services provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99232 
billed on date of service March 15, 2023. 
 
You asked the Plan to pay for 99232. You say that 99232 should be paid because the diagnosis codes billed are 
listed as payable and are supported in the medical record. The Plan denied your request. The Plan says two of 
the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that G30.9 has an Excludes1 note in relation to F03.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for 99232 have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation 
and management services coded as 99232 billed on date of service March 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 1, 2023, to May 8, 
2023. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the claim denied because the claim/service lacks information or has 
submission/billing error(s). 
 
The Plan must follow Medicare rules. Medicare rules say that when the CBSA is reported, the HHA reports the 
number in the dollar portion of the form locator and two zeros must be added to the cents field. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the CBSA code on the claim has not been 
reported correctly.  Therefore, we decided that the Plan does not have to pay for home health services provided 
on May 1, 2023, to 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 you say that you disagree with the denial for the 
admission to an IRF. The Plan denied your request. The Plan says these services are 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from September 13, 
2021, to September 22, 2021.  
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the denial for DRG 385 is upheld. 
 
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 provided with DRG 35. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the documentation does not consistently and completely support the assigned principal 
diagnosis code with DRG. The replacement of DRG is upheld as it is supported by the medical documentation. 
The documentation does not indicate that the treatment ordered by the treating medical providers supported a 
diagnosis code of K50.012 (Crohn's disease of small intestine with intestinal obstruction).  
 
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 rendered from September 13, 2021, to September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G. 
 
You asked the Plan to pre-approve MyoPro Motion G. 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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not the standard of care for this enrollee's condition or in widespread 
use for this enrollee'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 MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MyoPro Motion G.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 29, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were needed emergently. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J44.9 has an Excludes1 note in relation to J43.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on May 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415 and 83036) billed for date of 
service October 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says the records provided do not support the date 
of service reported. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. There are few exceptions to this rule. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the records show that the specimen in this case 
was collected on October 21, 2022. There is no evidence that any exception to the general date of service rule 
for laboratory services has been met. Therefore, we decided that the Plan does not have to pay for laboratory 
services (36415 and 83036) billed for date of service October 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 25, 2022. 
 
You asked the Plan to pay for the medical services. You say that the diagnoses billed were appropriate. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that S01.01XA has an Excludes1 note in relation to S00.83XA. This means 
that the two diagnosis codes cannot be reported together. Based on this information, we decided that the 
Medicare billing rules for the medical services have not been met. Therefore, we decided that the Plan does not 
have to pay for medical services provided on December 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair with multiple 
power option (K0842) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, and E2603). 
 You asked the Plan to pre-approve a Group 2 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options included with a K0842 group 2 power wheelchair with multiple power options. The Plan also says the 
electronic connection, harness, and expandable controller cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface).  
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 Multiple Power Option PWC (such as code 
K0842) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules also 
say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee does not use a ventilator mounted to a wheelchair. The documentation 
does not support that the enrollee is at high risk for development of a pressure ulcer, utilizes intermittent 
catheterization for bladder management, or needs a power seating system to manage increased tone or 
spasticity. Our reviewer found that the enrollee has no history of prior pressure ulcer with prior wheelchair use 
and no documentation of flap surgery. The power tilt and recline seating system exceeds the enrollee's medical 
needs. Our physician reviewer also found that the electronic connection, harness, and expandable controller 
exceed the enrollee's medical needs as their bilateral upper extremity strength and function support that they 
can control any power options with their own switches.  
 
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 Group 2 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power 
wheelchair with multiple power option (K0842) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, and E2603).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 5, 2023, to 
March 6, 2023.  
 You asked the Plan to pay for the home health services. You say that this claim was denied due to a 
demographics issue. 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 February 5, 2023. The NOA was not received by the Plan until March 23, 
2023. 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 home health services provided 
from February 5, 2023, to March 6, 2023.
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 the patient would benefit from a critical 
illness recovery hospital to allow for more time to maximize recovery and allow for a stable discharge. The 
Plan denied your request. The Plan says the patient is receiving appropriate inpatient acute care and is currently 
unstable for transfer to an LTACH. 
 
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 patient appears to be improving but is still somewhat unstable and requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The patient does not require services at the LTACH that are not already available at the 
current facility. Transfer to the LTACH is not medically necessary as the patient is not yet stable for transfer 
and it would not be clinically advantageous. Our reviewer also found that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gynecological cytopathology screening rendered on July 24, 
2023. 
 
You asked the Plan to pay for the cytopathology screening. You say that this claim has been paid in the past. 
The Plan denied your request. The Plan says this service exceeds the maximum benefit allowed by your plan.  
 
The Plan must follow Medicare rules. Medicare rules say that Pap tests and pelvic examinations are covered 
once every 24 months. You previously received a covered screening on July 22, 2022; therefore, the benefit 
was exhausted on this date of service. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cytopathology screening have not been met. Therefore, we decided that the Plan does not have 
to pay for gynecological cytopathology screening rendered on July 24, 2023.