Persius/hicric huggingface dataset:
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 enrollee clearly exceeds the criteria 
for a medically appropriate LTACH admission. The Plan denied your request. The Plan says the requested 
service 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 the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not clearly support that LTACH services are medically appropriate at this 
time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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 procedure code 99291 billed for date of service October 18, 
2022.  
 
You asked the Plan to pay for procedure code 99291. You say that the claim is billed correctly and should be 
paid. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thoracic-lumbar-sacral orthosis (TLSO), triplanar 
control, modular segmented spinal system (L0464). 
 You asked the Plan to pre-approve a lumbar orthosis. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request is not medically necessary because the 
medical record does not document the need for a back brace as part of the plan of case and the documentation 
submitted does not contain a written order for the orthotic. 
 
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 a lumbar orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of osteoporosis with kyphosis. As stated in the Local 
Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs - A55426: 
"All claims for items billed to Medicare require a written order/prescription from the treating practitioner as a 
condition for payment. This written order/prescription is referred to as the Standard Written Order (SWO)." 
Provided records in this case do not contain a signed SWO from the treating provider. 
 
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 lumbar orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a thoracic-lumbar-sacral orthosis (TLSO), triplanar control, modular segmented spinal 
system (L0464).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on October 23, 2022, to October 
27, 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 
records support the DRG billed. The Plan denied your request. The Plan says that payment of DRG 872 is not 
supported. 
 
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 primary diagnosis code A41.51, defined as Sepsis 
due to Escherichia coli, and secondary diagnosis code A41.59, defined as other Gram-negative sepsis. 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 there is clear documentation to support DRG 872, and diagnosis codes 
A41.51 and A41.59. Our physician reviewer found the enrollee had sepsis with fever, leukocytosis with culture 
positive of e-coli from urinary source, with acute kidney injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on October 23, 2022, to October 27, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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 lab services (87506) provided on January 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87506) provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on May 28, 2022. 
 
You asked the Plan to pay for nail debridement. You say that the services were medically necessary. The Plan 
denied your request. The Plan says nail debridement is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of nail 
debridement have not been met. Therefore, we decided that the Plan does not have to pay for nail debridement 
provided on May 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaker service, per 15 minutes (S5130). 
 
You asked the Plan to pre-approve homemaker service. You say that the enrollee is visually impaired and 
homebound. The enrollee struggles to move around in the home, daily tasks are extremely difficult, and he 
lives alone requiring maximum amount of in-home health aid services. The Plan denied your request. The Plan 
says the requested services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a homemaker service is not covered by Medicare 
or the Plan.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of homemaker service have not been met. Specifically, the homemaker service is not a covered 
benefit. The records show that the Plan has discussed services with the enrollees provider, that might be 
available to the enrollee, which requires a different code. Therefore, we decided that the Plan does not have to 
pre-approve homemaker service, per 15 minutes (S5130).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2023, 
through February 2, 2023.  
You asked the Plan to pay for the home health services. You say that the denial rationale is not appropriate as 
you do not have a contract with the Plan.  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 January 9, 2023. The NOA was not received by the Plan until March 10, 
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 the home health services 
provided from January 9, 2023, through February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 25, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the primary 
payer will need to review the services for payment consideration before this Plan can consider the claim for 
payment as the secondary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider and successfully relayed the information. As the secondary insurer, the Plan cannot be held 
responsible for the physician's services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for physician's services provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted neurological or neuromuscular diagnostic 
procedure provided on May 17, 2022. 
 
You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. You say that 
the services were medically necessary. The Plan denied your request. The Plan says no records have been 
received to support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the unlisted neurological or 
neuromuscular diagnostic procedure have been met. Medical records were not provided. Therefore, we decided 
that the Plan does not have to pay for an unlisted neurological or neuromuscular diagnostic procedure provided 
on May 17, 2022.
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 almost totally paralyzed and need extensive 
rehabilitation. You say your physical and occupational therapists say you really need extensive therapy. The 
Plan denied your request. The Plan says the request for admission to an IRF does not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 01942) rendered on 
August 18, 2022. 
 
You asked the Plan to pay for the services. You say that the services are medically necessary, and therefore 
payable. The Plan denied your request. The Plan says this service does not meet the coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 services 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 anesthesia time is 16:08 - 17:59 (which is 111 minutes)/15 minutes = 7.4 units. CPT 01942 has 5 
base units. Base units + Time units = 5 + 7.4 = 12.4 total units.  This number of units would then be multiplied by the conversion factor and any appropriate modifier. The submitted anesthesiology bill of 111 units is not 
supported in this case, and is not medically reasonable. 
 
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 pay for anesthesia services (procedure code 01942) rendered on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on January 9, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on January 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on February 15, 2023, billed 
with procedure code 77080-26. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that this service is not covered when considered 
preventative. 
 
The Plan must follow Medicare rules. Medicare rules say that the only covered diagnosis for a screening test 
are postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Contractors are to 
maintain local lists of valid codes for the benefit's screening categories.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. This claim was billed with diagnosis code Z13.820 which is not listed as a valid code for the service provided. Therefore, we decided that the Plan does 
not have to pay for radiological services provided on February 15, 2023, billed with procedure code 77080-26.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 31, 2022, to 
November 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you timely filed the NOA. 
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 October 1, 2023. The NOA was not received by the Plan until April 13, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Please note that although you claim that you filed the NOA timely, you did not send it 
timely to the Plan. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 31, 2022, to November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits, echocardiography, electrocardiogram and a 
chest computed tomography (CT) scan be provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve office visits, echocardiography, electrocardiogram and a chest computed 
tomography (CT) scan be provided by the requested out-of-network provider. You say that you have an 
aneurysm on the wall of your heart that is significantly large. You say that the surgeon you are seeing in 
Buffalo has not recommended doing the surgery because of the high risk as the aneurysm is closely attached to 
your mitral valve and there is damaged tissue surrounding it therefore, he suggested only monitoring it. You 
say that your primary care physician, cardiologist, and your cardiothoracic surgeon have recommended going 
to this clinic to get a second opinion. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. If you go elsewhere without proper authorization you will have 
to pay in full. The only exceptions are emergencies, urgently needed services when the network is not available (that is, in situations when it is unreasonable or not possible to obtain services in-network), out-of-area dialysis 
services, and cases in which the Plan authorizes use of out-of-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits, echocardiography, electrocardiogram and a chest computed tomography (CT) scan be provided by the 
requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report and the Hereditary 
Genetic Cardiac Test panel provided on December 27, 2022, and billed with codes 81225, 81226, 81227, 
81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the GeneDose Genetic Response Report and the Hereditary Genetic Cardiac Test 
panel. You say that this testing was medically necessary.  The Plan denied your request. The Plan says these 
tests should be billed with single panel codes. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components.  
We looked at the file and Medicare rules. These tests were not billed with single panel codes as required. Based 
on this information, we decided that Medicare rules for coverage of the GeneDose Genetic Response Report 
and the Hereditary Genetic Cardiac Test panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneDose Genetic Response Report and the Hereditary Genetic Cardiac Test panel 
provided on December 27, 2022, and billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 
81291, 81306, 81328, 81335, 81479, and 81238.