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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF criteria and requires 
intensive inpatient rehabilitation with daily physician management, continuous specialized rehabilitation 
nursing, and intensive therapies to optimize mobility and strengthening while ensuring the restoration of 
functional status for a safe and sustainable discharge. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on January 6, 2023.  
 
You asked the Plan to pay for the critical care services. You say that the services at issue should be reimbursed.  
The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.  
 The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes have Code first notes 
indicating they should not be used as primary diagnoses. 
 
We looked at the file and Medicare rules. The claim was billed with primary diagnosis code R65.10, systemic 
inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction. This code 
has a Code first note indicating to report the underlying condition first. Based on this information, we decided 
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the following services provided by a chiropractor from April 
18, 2023, t0 May 2, 2023: code 97124 (massage), code G8539 (functional outcome assessment), and code 
G8942 (another type of functional outcome assessment). 
 
You asked the Plan to pay for codes 97124, G8539, and G8942. You say that the Plan has covered previous 
visits with this provider. The Plan denied your request. The Plan says because you have been seeing this 
provider for a while, the Plan has agreed to pay for the manual manipulation of the spine code (98941).  
However, the Plan says that the other codes represent chiropractic services that are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the following services provided by a chiropractor from April 18, 2023, t0 
May 2, 2023: code 97124 (massage), code G8539 (functional outcome assessment), and code G8942 (another 
type of functional outcome assessment).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 skilled nursing home health visits and 8 physical 
therapy home health visits. 
 
You asked the Plan to pre-approve the additional home health services. You say that the services which remain 
in dispute are medically necessary. The Plan denied your request. The Plan says the services which remain in 
dispute are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. 
Our reviewer says that the services which remain in dispute are not medically reasonable and necessary. Our 
physician reviewer found the enrollee had back surgery on August 7, 2023. The records show that the enrollee 
can transfer modified independent and walk 30 feet stand-back-assist (SBA.) The records do not support that 
the enrollee is home bound or has a considerable and taxing effort to leave the home. The enrollee would be 
expected to improve with continued exercise.  
 
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 additional home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 skilled nursing home health visits and 8 physical therapy home 
health visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 30, 2023, to 
February 25, 2023. 
 You asked the Plan to pay for the home health services. You say that the enrollee did not tell you of their 
insurance change, so you were not able to submit the NOA timely. 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 30, 2023. The NOA was not received by the Plan until June 8, 
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 January 30, 2023, to February 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 83789) provided on March 24, 
2023. 
 
You asked the Plan to pay for drug testing services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says these services were not reported appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
In this case, the CPT Code Manual definition of code G0480 is drug test(s), definitive, includes specimen 
validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, the records provided do not support code 
G0480, as the records show that drugs from more than 7 classes were tested. There is a more appropriate code 
to report the services provided. In addition, we find that the testing described by code 83789 is not separately 
payable. Therefore, we decided that the Plan does not have to pay for drug testing services (G0480, 83789) 
provided on March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on January 30, 2023, billed 
with codes 87498, 87502, 87634, U0003 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 

The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on January 30, 2023, billed with codes 87498, 87502, 87634, U0003 and U0005.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the thorax (71250) provided 
on March 24, 2023. 
 
You asked the Plan to pay for the CT scan. You say that medical records submitted supports code 71250. The 
Plan denied your request. The Plan says this claim was billed with a primary diagnosis code that is not 
appropriate.  
The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes are manifestation codes 
and should not be sequenced before the etiology code. These codes have a "Code first" note. 
 
In this case, the CPT Code Manual definition of code 71250 is computed tomography (CT) of the thorax. 
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I21.A1 This code 
has a "Code first" note indicating to report the underlying disease first. As such, it is not an appropriate primary 
diagnosis. Based on this information, we decided that Medicare rules for coverage of the pathology services 
have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) of 
the thorax (71250) provided on March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62380 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 62380. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the service at issue was not billed 
with the required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 62380 
provided on July 28, 2022. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62380 billed for 
date of service September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99222) 
rendered on May 11, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the code and the modifier cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99222 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 minutes must be met or exceeded." 
 
We asked our coder 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 reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level, or that 55 
minutes were spent on the service, so CPT 99222 is not appropriate. 
 
We looked at this coder'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 evaluation and management services (procedure code 99222) rendered on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for hearing aids provided on January 5, 2023. 
 
You asked the Plan to reimburse more for hearing aids. You say that you were only sent $350 and should have 
received $700 back from the Plan, because you paid $1,599. The Plan denied your request. The Plan says their 
decision to apply member responsibility was correct. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for a 
reimbursement at 55% of the in-network allowed amount for hearing aids. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must pay 100% of the out-of-network 
cost and submit your itemized receipt(s) for reimbursement at 55% of the in-network allowed amount for 
hearing aids. The record shows that the allowed amount was $700, therefore you were reimbursed the correct 
amount ($700 x 55% = $385). Based on this information, we decided that the Plan's rules for coverage of 
hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse more for 
hearing aids provided on January 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted bladder laparoscopy procedure (51999) provided 
on March 29, 2023. 
 
You asked the Plan to pay for the bladder laparoscopy procedure. You say that this service was medically 
necessary and is supported in the medical records. The Plan denied your request. The Plan says this code has an 
assistant surgeon indicator of 0, and therefore is not reimbursable. 
 
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 pay for the bladder laparoscopy procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that it was not medically necessary for there to be a surgical assistant (PA-
C) for procedure code 51999. However, review of the operative report shows that 51999 was not performed. 
The actual procedure performed was 55867 and a surgical assistant fee is covered for that. 
 
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 bladder laparoscopy procedure have not been met. Therefore, we decided 
that the Plan does not have to pay for the unlisted bladder laparoscopy procedure (51999) provided on March 
29, 2023.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH 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 already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous.  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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 27, 2022, to 
December 26, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
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 May 31, 2022. The NOA was not received by the Plan until February 22, 
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 November 27, 2022, to December 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2023, billed with 
codes 87798-59, 87481-59, 87653-59, 87640-59, 87471-59, 87641-59, and 87500-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary.  The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 4, 2023, billed with codes 87798-59, 87481-59, 87653-59, 87640-59, 87471-59, 87641-59, and 87500-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block provided on June 9, 2022. 
 
You asked the Plan to pay for the genicular nerve block. You say that the nerve block was necessary to help the 
enrollee with pain management. The Plan denied your request. The Plan says the genicular nerve block is 
considered investigational and 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 pay for the genicular nerve block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an experimental/ investigational procedure. It is the subject of 
ongoing clinical trials.   
 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve block provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 3, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 3, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 
81272.