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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that without IRF services the enrollee's ability to regain 
maximum function will be seriously jeopardized. The Plan denied your request. The Plan says the IRF services 
requested 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 that the complexity of the enrollees 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. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (87631-59), 
noninvasive ear or pulse oximetry for oxygen saturation (94761-59), additional supplies (99072-59) provided 
on November 2, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of 99072 have not been met. Procedure 94761 has a status indicator of T on the CMS National 
Physician Fee Schedule (NPFS) Relative Value (RVU) file. This means this service is always bundled into 
another payable physician service, 99214, billed the same day by the same provider. For code 87631, all MDT 
services must include an identifier as additional claim documentation. Test providers must receive an identifier 
specific to the applicable test and submit the test assigned identifier with the claim for reimbursement. The 
assigned identifier will provide a crosswalk between the test's associated detail information on file and the 
submitted claim detail line(s) required to adjudicate each test's claim. The MolDX Program requires 
laboratories to obtain a test-specific identifier - a DEX Z-Code -that is unique to the laboratory's specific test 
(i.e., the unique test identifier establishes a link to the specific test performed). When reported in conjunction 
with the appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System 
(HCPCS) code, the identifier allows payers to determine the exact, test that has been performed, facilitating 
the process of making pricing and/or coverage determinations. 
 
We looked at 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 pay for 
infectious agent detection by nucleic acid (87631-59), noninvasive ear or pulse oximetry for oxygen saturation 
(94761-59), additional supplies (99072-59) provided on November 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 12, 2022, to July 
15, 2022, at the Diagnosis Related Group (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 support the DRG originally billed. The Plan denied your request. The Plan says although the 
diagnosis J15.6 (Pneumonia due to other gram-negative bacteria) is documented, reasonable clinical evidence 
within the health record is not present to clinically validate the diagnosis. As a result, a lower DRG was paid. 
 
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 diagnosis J15.6 (Pneumonia due to other gram-
negative bacteria). 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 billed diagnosis J15.6 (Pneumonia due to other 
gram-negative bacteria) is not supported in the medical record. Our physician reviewer found the enrollee was 
evaluated for chest pain.  He was treated for a peritoneal dialysis problem, acute-on-chronic heart failure and 
possible pneumonia.  There is no evidence that a gram-negative organism was identified as the cause of the 
enrollees possible pneumonia.  As such, the billing of J15.6 is not supported.  
 
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 on July 12, 2022, to July 15, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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 are requesting an appeal for the denial of an IRF 
admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like this claim reviewed for approval of the necessary electronics for the power wheelchair. The 
Plan denied your request. The Plan says these items cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter. 
 
You asked the Plan to pre-approve a scooter. You say that you would like a scooter to use to go out and run 
quick errands. You also say that your legs give out on you if you are on your feet for too long, and are more 
painful. The Plan denied your request. The Plan says there is no evidence that a power operated vehicle (POV) 
is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 scooter. Our reviewer says that a 
scooter is not medically reasonable and necessary for you. Our physician reviewer found on the therapy 
evaluation you were able to ambulate fully throughout your apartment. Our reviewer also found that you do not 
require use of a POV to manage MRADLs in the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47490 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 47490. You say that this diagnosis code is appropriate and 
accurate for the date in question. The Plan denied your request. The Plan says this claim was not billed with an 
appropriate primary diagnosis as directed by Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that manifestation codes have a "code first" note and should be sequenced after an appropriate 
etiology code.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 47490 have not been met. Specifically, the only/primary diagnosis reported on this 
claim is K82.A2 (perforation of gallbladder in cholecystitis). Diagnosis codes within the K82.A code set have a 
"code first" note, instructing providers to report the type of cholecystitis (K81.-), or cholelithiasis with 
cholecystitis (K80.00-K80.19, K80.40-K80.47, K80.60-K80.67) before a K82.A code. This means that it is not 
appropriate to use this diagnosis code alone or as a primary diagnosis. Therefore, we decided that the Plan does 
not have to pay for procedure code 47490 billed for date of service December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 billed for date of service January 4, 
2023.  
You asked the Plan to pay for procedure code 69209. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 5 for CPT code 69209. This means these 
codes describe services covered incident to a physician service when they are provided by auxiliary personnel 
employed by the physician and working under his or her direct supervision. Payment may not be made by 
carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient 
department. In this case, the services were billed in the emergency room (hospital). Based on this information, 
we decided that Medicare rules for coverage of procedure code 69209 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 69209 billed for date of service January 4, 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 ready for discharge and all physicians 
are waiting and recommending inpatient acute rehabilitation. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory pathology services (88305, 88342) billed for date 
of service October 2, 2022. 
 
You asked the Plan to pay for laboratory pathology services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory pathology services have not been met. Specifically, the records suggest that these 
services were rendered in an inpatient setting. The codes at issue have a professional/technical component 
indicator of 1. This means that these codes have a professional and technical component. These codes have not 
been billed with the appropriate modifier to indicate that they are for the professional component. Payment for 
the technical component of these codes is included in the payment to the facility and is the responsibility of the 
facility to any vendor. Therefore, we decided that the Plan does not have to pay for laboratory pathology 
services (88305, 88342) billed for date of service October 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71046) provided on June 27, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says the amount was applied to the enrollee's deductible. 
 
The Plan must follow Medicare rules. Review of the file shows that the claim did not deny; however, an $81.42 
deductible was applied. The Medicare eligible amount for code 71406, $81.42, was applied to deductible to be 
paid by the enrollee. We looked at the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not 
have to pay for the chest x-ray (71046) provided on June 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on November 30, 2022, billed with 
code 77080. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that Contractors will pay claims for screening tests 
when coded with a valid diagnosis code indicating the reason for the test is postmenopausal female, vertebral 
fracture, hyperparathyroidism, or steroid therapy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. Procedure code 77080 was billed with diagnosis code Z13.820 which is not a valid diagnosis for this service. Therefore, we decided that the Plan does not have 
to pay for testing services provided on November 30, 2022, billed with code 77080.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DaT SPECT scan. 
 
You asked the Plan to pre-approve a DaT SPECT scan. You say that a DaT SPECT scan is medically 
necessary. The Plan denied your request. The Plan says a DaT SPECT scan is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria listed in the 
Medicare rules section of this decision 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 a DaT SPECT scan. Our reviewer says 
that the requested DaT SPECT scan is not considered medically necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that the DaT SPECT scan at issue 
in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The provided 
records in this case do not document the need to evaluate the enrollee for a stress fracture or spondylosis or 
infection (e.g., discitis) or tumor (e.g., osteoid osteoma) or to analyze blood flow to an organ, as in the case of 
myocardial viability or to differentiate ischemic heart disease from dilated cardiomyopathy or to differentiate 
Parkinsonian Syndromes (Parkinson Disease, Multiple System Atrophy, Progressive Supranuclear Palsy, 
Corticobasal Degeneration) from essential tremor and drug-induced tremor when the diagnosis remains unclear 
after evaluation by a neurologist, medication trials and brain imaging as required by the National Coverage 
Determination - Single Photon Emission Computed Tomography (SPECT) (220.12) and Social Security Act, 
Section 1862 (a)(1)(A). 
 
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 DaT SPECT scan. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a DaT SPECT scan.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 
17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on December 27, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed items/services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99285 billed for date of service 
November 17, 2022.