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

 
We decided that the Plan does not have to pay for the assistant surgery services provided on May 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgery 
services are not covered for this code. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 26418. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgery 
services provided on May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Nalu PNS System. 
 
You asked the Plan to pre-approve the Nalu PNS System. You say that the Nalu PNS System is medically 
necessary. The Plan denied your request. The Plan says the requested Nalu PNS System 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 Nalu PNS System. Our reviewer 
says that the requested Nalu PNS System is not considered medically reasonable and necessary. Our physician 
reviewer found that this is considered an experimental/investigational procedure. It is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 Nalu PNS System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Nalu PNS System.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 16, 2023, and billed with 
codes 87798, 87640, 87651 and 87641. 
 
You asked the Plan to pay for laboratory testing. 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 for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory testing provided on June 16, 2023, and billed with codes 87798, 
87640, 87651 and 87641.
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 IRF services and meets all 
necessary guidelines for an IRF admission. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for approval of the requested IRF services.  
 
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 and there are no complex nursing or rehabilitation needs. Medically necessary 
services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2023, billed with 
codes 81235, 81401, 81275, 81210, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the genetic testing billed should be 
covered because it was medically necessary for treatment of the enrollee. 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 
July 13, 2023, billed with codes 81235, 81401, 81275, 81210, and 81479.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 You asked the Plan to pre-approve continued SNF care. You say that continued SNF services are medically 
necessary. The Plan denied your request. The Plan says you do not meet the Medicare criteria for continued 
skilled nursing facility (SNF) care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require continued daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.
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 an IRF stay and close physician 
supervision to return to her maximum level of functioning. 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but services required can be provided at 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 You asked the Plan to pre-approve continued SNF care. You say that continued SNF is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
continued skilled nursing facility (SNF) care.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 approve continued SNF care. Our reviewer says that 
the requested continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies at a 
skilled nursing facility (SNF) may be approved upon request.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at 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: 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 needs this care to return to previous 
level of function before returning home. The Plan denied your request. The Plan says medical records do not 
support the need for an IRF admission and, the enrollee needs can be provided at another setting.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that coding of sequela generally requires two codes 
sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is 
sequenced second. 
 
We looked at the file and Medicare rules. In this case, the sequela diagnosis code was inappropriately billed as 
the primary diagnosis. The sequela code should be sequenced second. 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 the services provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula (B4150). 
 
You asked the Plan to pre-approve enteral formula. You say that the enrollee has been experiencing nausea and 
decreased appetite as a result of current treatments. You also say that the requested supplements are necessary 
for the enrollee to maintain their weight. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral formula (B4150).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on December 23, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on December 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 5, 2023. 
 
You asked the Plan to pay for procedure code 99285. The Plan denied your request. The Plan says payment for 
code 99285 is bundled into payment for code 99291.  
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 99285 
is a column II code to column I code 99291. 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 99285 billed for date of service July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service June 28, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the documentation shows the services were 
required. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The file shows that a urinary tract infection panel was billed with procedure codes 87801, 87798, 87651, 
87641, 87481, and 87150. We looked at the file and Medicare rules. The documentation supports that this panel 
used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, 
or multiple kits were used in this case. As such, a single code with one unit of service should be used. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing billed for date of service June 28, 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 it is a medical necessity for you to have IRF services. 
The Plan denied your request. The Plan says you do 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 the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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.