Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (20930), and autograft (20936), arthrodesis 
(22551), anterior segmentation (22845), insertion of interbody biomechanical device (22853). 
 
You asked the Plan to pre-approve an allograft, and autograft, arthrodesis, anterior segmentation, insertion of 
interbody biomechanical device. You say that this is medically necessary. The Plan denied your request. The 
Plan says this is not medically necessary. 
 
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 allograft, and autograft, arthrodesis, 
anterior segmentation, insertion of interbody biomechanical device. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of a six week to three month recent trial of physical therapy for neck pain.  
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 allograft, and autograft, arthrodesis, anterior segmentation, insertion of 
interbody biomechanical device have not been met. Therefore, we decided that the Plan does not have to pre-
approve an allograft (20930), and autograft (20936), arthrodesis (22551), anterior segmentation (22845), 
insertion of interbody biomechanical device (22853).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary and cannot be 
provided in a lower level of care. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services (99308, 99309) provided on January 20, 
2023 to March 17, 2023. 
 
You asked the Plan to pay for the wound care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed codes cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99308, & 99309 are not supported in the medical record. Specifically, multiple 
instances of the billed codes were reported within a 14 day period. Based on this information, we decided that Medicare rules for coverage of the wound care services have not been met. Therefore, we decided that the Plan 
does not have to pay for wound care services (99308, 99309) provided on January 20, 2023 to March 17, 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 requires interdisciplinary therapy 
services to regain their prior level of function. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
MRI of the brain is not medically necessary. Our physician reviewer found that the provided documentation 
describes the enrollee with stable vital, mini mental state examination score of 28/30, and physical findings 
showing no neurological deficits. There was no evidence of dementia or delirium on examination and testing, 
nor was there any signs of red flag diagnoses that would warrant advanced imaging at this time. Therefore, 
without sufficient support made for this request, the MRI brain will be considered not medically necessary 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the brain.
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 a fall risk and requires therapy 
services to return to their prior level of function. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is a fall risk and requires therapy services to return to their prior level of 
function. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unattended sleep study (95806).  
You asked the Plan to pre-approve an unattended sleep study. The Plan denied your request. The Plan says the 
clinical information does not show choking or gasping during sleep, morning headaches, neck circumference, 
or duration and number of apnea episodes. The Plan also says the clinical information states the enrollee is not 
willing to use positive airway pressure therapy again because they cannot tolerate a mask on their face. 
 
The Plan follows Medicare rules. Medicare rules say that repeat PSG should not be routinely indicated for the 
assessment of treatment results in patients whose symptoms continue to be resolved with PAP treatment. 
 
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 unattended sleep study. Our 
reviewer says that an unattended sleep study is not medically necessary. Our physician reviewer found this 
enrollee has a prior diagnosis of obstructive sleep apnea, but reports intolerance of CPAP, and is not willing to 
try it again. Our reviewer found that it therefore appears there is no benefit to the enrollee undergoing a 
polysomnography. 
 
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 unattended sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an unattended sleep study (95806).
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 requires a multidisciplinary 
team of specialists for medical management of their care needs. The Plan denied your request. The Plan says 
when the enrollee is ready to leave the hospital their care needs can be met in another setting. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 2, 2023, to 
March 31, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted electronically, 
but it was rejected. The Plan denied your request. The Plan says the NOA was not received.  As such, this final 
claim was correctly denied. The Plan says that although you claim the NOA was submitted, no NOA has been 
received by the Plan. 
 
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 NOA has not been received by the Plan. As a result, 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 March 2, 
2023, to March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 28, 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 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 provided on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
January 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 9, 2022, to July 
5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was sent and 
acknowledged by the Plan. 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 June 9, 2022, to July 5, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70553 for date of service February 15, 2023. 
 
You asked the Plan to pay for procedure code 70553. 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. An 
Excludes1 note indicates that the code excluded should never be used at the same time as the code above the 
Excludes1 note. 
 
 We find that CPT code 70553 is not payable as billed. Specifically, this code was billed with diagnosis codes 
G31.84 (Mild cognitive impairment of uncertain or unknown etiology) and I67.82 (Cerebral ischemia). Due to 
an Excludes1 note, these two diagnosis codes should not be billed together. The claim is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of procedure code 70553 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 70553 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 care billed for dates of service May 19, 
2022, to June 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim should not have been reprocessed. The 
Plan denied your request. The Plan says documentation was not submitted for review. 
 
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. In this case, medical records were not provided to show that the 
services were medically necessary. The file does show that the Plan made multiple attempts to obtain additional 
information with no success. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health care billed for dates 
of service May 19, 2022, to June 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 15, 2022. 
 You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. 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 December 15, 2022. The NOA was not received by the Plan until January 
19, 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 
on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
December 7, 2022, and billed with codes 87481 and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
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. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on December 7, 2022, and billed with codes 87481 and 87798.
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 a long term acute care hospital is needed 
for management of the enrollee's respiratory failure. The Plan denied your request. The Plan says a stay in a 
long term acute care hospital 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 does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve the ILR device. You say that the enrollee needs this device. The Plan denied 
your request. The Plan says that this device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an implantable loop recorder (ILR) is used when 
syncope is thought to be cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a 
traditional pre-symptom MLR.  
 
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 ILR device. Our reviewer says that 
the requested implantable loop recorder (ILR) device is considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation indicates the enrollee has a recent history of cryptogenic 
stroke. The reviewer found that the enrollee had undergone prolonged noninvasive heart monitoring which was 
inconclusive. Therefore, the reviewer found that the requested ILR device is medically reasonable and 
necessary in this case. 
 
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 ILR device have been met. Therefore, we decided that the Plan has to pre-
approve an implantable loop recorder (ILR) device.  
 
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.