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

 
We decided that the Plan does not have to pre-approve a neurostimulator electrode array (63650). 
 
You asked the Plan to pre-approve a neurostimulator electrode array. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not medically necessary because your records do not show 
documentation of multidisciplinary team assessment including evaluation by psychology. 
 The Plan follows Medicare rules. Medicare rules say that neurostimulator implantation can be covered when 
specific criteria 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 neurostimulator electrode array. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation of a multi-disciplinary approach. There is no surgical consult, physical medicine or physical 
therapy. There is no psychological evaluation of the patient. 
 
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 neurostimulator electrode array have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a neurostimulator electrode array (63650).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on April 26, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
April 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 12, 2022, to 
January 10, 2023. 
 You asked the Plan to pay for the home health services. You say that you timely filed your claim. 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 November 12, 2022. The NOA was not received by the Plan until March 
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 December 12, 2022, to January 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH and is 
stable for discharge. You say you have grave concerns about discharge to any lower level of care as it would 
likely result in recurrent hospitalization, morbidity and potential mortality. The Plan denied your request. The 
Plan says based on Medicare guidelines, the LTACH services requested do not meet the requirements for 
approval. 
 
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 has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services and these have not been denied by the Plan. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0953, E0955, E1002, E1012, E1028, E2311, 
E2313, E2361, E2377, E2607, E2613, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee is unable to perform independent pressure reliefs, requiring the use of power seating 
functions on a group 3 wheelchair. The Plan denied your request. The Plan says the enrollee does not have 
medical need for single power options included with group 3 power wheelchair. The Plan also says wheelchair 
electronics cannot be covered as it is not medically necessary to control the requested power options through 
the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say if the base power wheelchair is not covered, all related accessories will also be denied. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee had a stroke in 2011, and the left hemiparesis prevents 
them from using a manual wheelchair. The enrollee can stand and walk short distances. The enrollee has 
dementia with behavior disturbances. Our reviewer found that the enrollee's functional loss has been present for 
12 years and their skin is intact. The enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. Our physician reviewer 
also found that the enrollee's dementia makes their independent use and safety with a power wheelchair 
potentially unsafe, and the record does not address the safety issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0953, E0955, 
E1002, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2613, and K0040).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798 and 87801 billed for 
date of service February 7, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87653, 87798 and 87801. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87801 is: Infectious agent detection by nucleic acid 
(DNA or RNA), multiple organisms; amplified probe(s) technique. 
 
In this case, we have confirmed that codes 87481, 87653 and 87798 are column II codes to column I code 
87801; however, 87481, 87653 and 87798 were billed with a modifier. 
 
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 procedure codes 87481, 87653, 87798 and 87801. Our 
reviewer says that procedure codes 87481, 87653, 87798 and 87801 do not meet criteria for payment. Our 
reviewer found that the provided medical records do not support 3 units of procedure code 87801. This code 
description includes multiple organisms and should be reported once per encounter. Codes 87653, 87798 and 
87481 are not supported as separately reportable tests. These are included in 87801 and should not be reported 
with modifier XU. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653, 87798 and 87801 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798 and 87801 billed for 
date of service February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, 96521, and J1817 for date of service 
February 17, 2023. 
 
You asked the Plan to pay for codes 96365, 96366, 96521, and J1817. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, the 
documentation shows that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by 
any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); 
and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. This means codes 
96365 and 96366 are not supported. There is a more appropriate code to be billed for the services rendered. The medical records submitted include an order to perform refilling and maintenance of portable pump. However, 
the records indicate that Outpatient Intravenous Insulin Treatment (OIVIT) was performed and does not 
include a procedure report for pump maintenance refill. Therefore, code 96521 cannot be verified. The medical 
records indicate Humulin R was administered via intravenous treatment. This means there is a more 
appropriate code to be billed for the services rendered and code J1817 is not supported. Based on this 
information, we decided that Medicare rules for coverage of codes 96365, 96366, 96521, and J1817 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 96365, 96366, 96521, and J1817 
for date of service February 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service March 30, 
2023. 
 You asked the Plan to pay for procedure code 93355. The Plan denied your request. The Plan says payment for 
code 93355 is bundled into payment for code 00560. 
 
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, we have confirmed that code 93355 
is a column II code to column I code 00560. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93355 billed for date of service March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 99053 billed for February 11, 
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 services are not covered. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there are no records for the 
billed date of service. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met.  
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. 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 procedure codes 99291 and 99053 billed for 
February 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have worked with physical and occupational 
therapy who have recommended daily therapy prior to going home so that you can get back to a high level of 
function and independence. The Plan denied your request. The Plan says based on Medicare guidelines, 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You require treatment by 
multiple therapies, including physical therapy and occupational therapy, but these can be provided in a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 require a scooter because you can barely walk, 
and your muscles have contracted due to lack of exercise. You also say that you are scheduled for a hip 
replacement, your right heel has fractured, and walking is unbearable for you on both legs. The Plan denied 
your request. The Plan says the notes to not support the need. 
 
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 you 
do not meet the criteria for coverage. Our physician reviewer found the documentation available for review 
does not support that you require a power mobility device to accomplish mobility related self-care tasks in the 
home. Our reviewer also found that there is no indication that you are unable to use an alternative assistive 
device. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0315U billed for February 28, 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 procedure code 0315U is not supported. 
 
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 0315U is oncology (cutaneous squamous cell carcinoma), 
mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-
fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, 
Class 2B). 
 
We find that CPT code 0315U is not supported in the medical record. Specifically, there is no documentation of an interpretation and report indicating a targeted genomic sequence analysis panel of 83 or more genes. 
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 procedure code 0315U billed for February 28, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 1, 2023, to 
February 27, 2023. 
 You asked the Plan to pay for the home health services. You say that payment should not have been denied in 
full, only reduced. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 1, 2023. The NOA was not received by the Plan until April 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 home health services provided 
from February 1, 2023, to February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 for date of service September 10, 
2022. 
 
You asked the Plan to pay for procedure code 99239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says it is inappropriate to bill place of service 21 for this service. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not payable as billed. Specifically, the documentation shows that the enrollee 
was registered outpatient hospital. This means it is inappropriate to bill place of service 21 (inpatient) for this 
service. This service is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99239 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99239 for date of service September 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36012 and 75827 billed for January 3, 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 procedure codes 36012 and 75827 are not supported. 
 
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 36012 is selective catheter placement, venous system; 
second order, or more selective, branch (eg, left adrenal vein, petrosal sinus). The definition of code 75827 is 
venography, caval, superior, with serialography, radiological supervision and interpretation. 
 
We find that CPT codes 36012 and 75827 are not supported in the medical record. Specifically, there is no 
documentation of selective catheter placement, venous system, second order, to support code 36012. There is 
no documentation of a venography, caval, superior, with serialography to support code 75827. 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 procedure codes 36012 and 75827 billed for January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in need of the long-term 
acute care in order to regain maximum function. The Plan denied your request. The Plan says the enrollee's 
records do not show to require an average 25 day stay in the LTACH or needed continued treatments that can 
only be given in a hospital setting. Services are being provided in the current hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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.