Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81455) provided on August 3, 2022, and August 
17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
covered by Medicare. The Plan denied your request. The Plan says that these services are denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated or fully 
explained their denial in this case. Therefore, we decided that the Plan has to pay for laboratory services 
(81455) provided on August 3, 2022, and August 17, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 20, 2022, to 
April 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of principal diagnosis code A41.9.  The Plan denied your request. The Plan 
says the medical records do not support the billing of principal diagnosis code A41.9.  
 
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 A41.9. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the medical records do not support the billing of principal diagnosis code A41.9.  Our physician reviewer 
found the review indicates that the enrollee presented to the emergency department on April 20, 2022, with 
weakness. She had a recent hospitalization for a urinary tract infection. She was evaluated and had a temp of 
101.4 and swelling of the right leg. Her white blood cell count was elevated to 18T. She was placed on IV 
antibiotics and admitted. In this case, there was no clinical or laboratory evidence of sepsis. The review has 
determined that the documentation did not support A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 20, 2022, to April 25, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC (0315U) provided on November 24, 2022. 
 
You asked the Plan to pay for DecisionDx-SCC. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test has not met Medicare criteria and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC have not been met. Therefore, we decided that the Plan does 
not have to pay for DecisionDx-SCC (0315U) provided on November 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A0431 and A0436 for date of service June 3, 2021. 
 
You asked the Plan to pay for codes A0431 and A0436. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the codes are not payable as billed. 
 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 A0431 and A0436 are not supported in the medical record. Specifically, these services 
were billed with modifier GZ. This modifier indicates that the provider expects denial due to lack of medical 
necessity. Claim lines with GZ modifier are specifically not covered. This means the claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of codes A0431 and A0436 
have not been met. Therefore, we decided that the Plan does not have to pay for codes A0431 and A0436 for 
date of service June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) with a neurologist to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you must receive medical services from an in-
network provider. There are in-network providers available for this service. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99203) with a neurologist to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 2, 2022, to May 31, 
2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required 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 March 17, 2022. The NOA was not received by the Plan until July 27, 
2022. 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 May 2, 2022, to May 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care. 
 
You asked the Plan to pre-approve custodial care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve custodial care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal fluid drain to be provided at an acute inpatient 
level of care. 
 
You asked the Plan to pre-approve the inpatient level of care. You say that the enrollee will require physical 
therapy (PT) and occupational therapy (OT) visits. You also say that PT and OT will not perform services under observation care. The Plan denied your request. The Plan says the request for the procedure to be 
performed at an inpatient level of care 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 the inpatient level of care. Our reviewer 
says that the requested inpatient level of care is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee is scheduled for placement of a spinal fluid 
drain trial that may exceed two days. The records provided are insufficient to support the need for inpatient 
level acute care. Therefore, the reviewer found that the request for the services to be performed at the inpatient 
level of care is not medically reasonable or necessary. 
 
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 inpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal fluid drain to be provided at an acute inpatient level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99215) provided on December 8, 2022. 
 
You asked the Plan to pay for physician services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 code 99215 is not supported in the medical record. Specifically, code 99215 is included in 
the global surgery package of codes 17276 and 17004 which were billed on the same date. Based on this 
information, we decided that Medicare rules for coverage of physician services have not been met. Therefore, 
we decided that the Plan does not have to pay for physician services (99215) provided on December 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A0428 and A0425 for date of service February 14, 
2023. 
 
You asked the Plan to pay for codes A0428 and A0425. 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. 
Providers must report services with the appropriate CPT code. 
 
We find that codes are not supported in the medical record. Specifically, when there is a "code first" note and 
an underlying condition is present, the underlying condition should be sequenced first, if known. These 
services were billed with diagnosis J12.82. This diagnosis code has a code first note to bill U07.1 as a primary 
diagnosis. This claim is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of codes A0428 and A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes A0428 and A0425 for date of service February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says two radiofrequency ablation sessions have 
already been rendered for the 12-month rolling period. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that you have had 2 
radiofrequency ablation sessions within the last 12 months, on June 23, 2022, and January 3, 2023. Based on 
this information, we decided that Medicare rules for coverage of radiofrequency ablation services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) scan showing only modic changes without 
facet degenerative joint disease or foraminal stenosis. The cause of the enrollee's back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchmen device. 
 
You asked the Plan to pre-approve the Watchmen device. You say that the Watchmen procedure is medically 
necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for the Watchmen 
procedure.  
 
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 the Watchmen device. Our reviewer 
says that the enrollee does not meet criteria for the Watchmen procedure.  Our physician reviewer found the 
enrollee has an elevated risk of thromboembolic stroke due to atrial fibrillation and elevated CHADS2-VASc 
score. There is no apparent contraindication to anticoagulation. As such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollee's clinical management. 
 
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 Watchmen device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Watchmen device.
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 unable to do anything with your legs and 
require therapy services at this time. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 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: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve an MRI. You say that you are appealing the denial of an MRI.  The Plan 
denied your request. The Plan says that the request for an MRI is denied as 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 an MRI. Our reviewer says that the 
service is medically necessary. Our physician reviewer found that based upon the history, the next step in the 
workup would be an MRI of the brain to assess the hippocampus to rule in or rule out Alzheimer's disease as 
the root cause of the enrollee's symptoms. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain.  
 
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: 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 need 24-monitoring, provision oversight for 
multiple therapies, and administering of medication. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from July 12, 2021, to 
July 17, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis codes are supported and the billed DRG is accurate for the enrollee's conditions. You say that you 
request proper reimbursement for the services rendered. The Plan denied your request. The Plan says the 
diagnosis codes are not supported, which resulted in a DRG change. 
 
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 with diagnosis codes G92 and G93.49, defined as toxic 
encephalopathy and other encephalopathy. 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 diagnosis codes G92 and 
G93.49 are not supported. Our physician reviewer found that the enrollee presented with abdominal pain and 
was not in any acute distress. Reports of prior hyperglycemia-related confusion was not present during the 
hospital stay. There was insufficient support made for encephalopathy as the documentation did not describe 
mental status decline beyond baseline.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from July 12, 2021, to July 17, 2021, at the DRG originally billed.