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

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee has dementia, and it is not safe for them 
to go home because they live alone. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary. 
 
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 SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy services rendered from August 9, 2022 to 
August 29, 2022. 
 
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 provider did not bill as required by Medicare coding regulations. 
 
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 the denied codes is: 
 
CPT 77290: 
 
Therapeutic radiology simulation-aided field setting; complex  
CPT 77300: 
 
Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis 
factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required 
during course of treatment, only when prescribed by the treating physician 
 
CPT 77301: 
 
Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure 
partial tolerance specifications 
 
CPT 77334: 
 
Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, 
molds or casts) 
 
CPT 77336: 
 
Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of 
dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported 
per week of therapy 
 
CPT 77338: 
 
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and 
construction per IMRT plan 
 
CPT 77373: 
 
Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image 
guidance, entire course not to exceed 5 fractions 
 
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 medical record does not 
include documentation to support that it was appropriate to report these procedures separately from the code for 
intensity modulated radiation therapy (IMRT) planning - CPT 77301. 
 
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 radiation therapy services rendered from August 9, 2022 to August 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department (ED) services provided on March 4, 
2023. 
 
You asked the Plan to pay for the ED services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says your facility is not a valid Medicare provider and you 
have provided no evidence that you can bill Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that generally, licensed independent freestanding 
emergency departments (EDs) cannot bill Medicare.  However, during the COVID-19 Public Health 
Emergency, these providers can become temporary Medicare providers if they meet certain criteria. 
 
In this case, there is no evidence that your facility meets any of the criteria listed above in order to receive 
Medicare payment.  There is no evidence that your facility is affiliated with a hospital, and you have provided 
no evidence that you have completed the temporary enrollment process to become a Medicare hospital.  As a 
result, payment to your facility cannot be made. 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ED services have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency department (ED) services provided on March 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Positron Emissions Tomography (PET) scan provided on 
December 8, 2022. 
 
You asked the Plan to pay for the PET scan. You say that this claim has been coded correctly. The Plan denied 
your request. The Plan says you did not bill this service with a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for PET scans to be covered, it must be 
billed with a covered diagnosis.  Covered diagnoses are listed in the diagnosis listing associated with the 
National Coverage Determination. 
 
In this case, you billed this PET scan with three diagnosis codes: C34.90, R59.0, and J18.1.  None of these 
three diagnosis codes is listed as a covered code in the aforementioned diagnosis listing. We looked at the file 
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan 
have not been met. Therefore, we decided that the Plan does not have to pay for the Positron Emissions 
Tomography (PET) scan provided on December 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 93010 rendered on January 27, 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 records do not support the services 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.

In this case, the CPT Code Manual definition of code 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only."

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 based on the medical records provided there is documentation that "numerous" electrocardiograms (ECG's) were performed and necessary for monitoring during a coronary catheterization procedure, but records do not clarify that five ECGs were inadequate and seven ECGs were reasonable and necessary to properly care for the enrollee in this case.

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 procedure code 93010 rendered on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (code 
99239) billed for date of service February 23, 2023. 
 
You asked the Plan to pay for code 99239. You say that this claim is not a duplicate.  This patient was seen by 
a different doctor on the same day. The Plan denied your request. The Plan says a hospital discharge day 
management code has already been paid for this patient. 
 
The Plan must follow Medicare rules. Medicare rules say that only one hospital inpatient or observation 
discharge day management service is payable per patient per hospital stay. 
 
In this case, another claim has already been paid for hospital discharge day management services for this 
patient.  Regardless of how many doctors may see the patient on discharge day, only one discharge day 
management service is payable. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for the 
hospital discharge day management services (code 99239) billed for date of service February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for wound supplies provided on January 17, 2023. 
 
You asked the Plan to pay for the wound supplies. You say that these items were shipped to the member and 
not incident to a physician's service. The Plan denied your request. The Plan says that these items are not 
separately payable. 
 
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's sole rationale for denial appears to be that the wound 
supplies in dispute are bundled under the physician fee schedule.  It may be true that the wound supplies billed 
are bundled under the physician fee schedule.  However, these wound supplies were NOT provided with a 
physician's service.  Rather, it is clear from the supporting documentation provided that you are a Durable 
Medical Equipment (DME) vendor. The records also confirm that these items were shipped to the member, not 
provided during the course of a physician service.  As a result, payment for these items would be based on the 
DME fee schedule, NOT the physician fee schedule.  There is no such bundling rule for DME items.  Further, 
you have provided adequate documentation of a physician order, a packing slip, and proof of delivery.  The 
Plan has failed to address payment of these items under the DME fee schedule as would be appropriate.  The 
Plan has failed to provide explanation as to why it is applying a physician fee schedule rule to a DME claim.  
The burden is on the Plan to show why its denial is appropriate.  By failing to supply this information, we find 
that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for wound supplies 
provided on January 17, 2023.  
 
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, 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 this enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 01924 billed for date of service May 19, 2022. 
 
You asked the Plan to pay for code 01924. You say that this claim was underpaid. The Plan denied your 
request. The Plan says you billed the diagnosis codes incorrectly on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers need to bill diagnosis codes correctly.  
Providers should bill codes to indicate if a condition exists unilaterally or bilaterally.  If the condition exists 
bilaterally, the provider should bill the bilateral ICD-10 code (if one exists. 
 
In this case, you billed ICD-10 codes I70.202 (Unspecified atherosclerosis of native arteries of extremities, left 
leg) and code I70.201 (Unspecified atherosclerosis of native arteries of extremities, right leg).  However, a 
bilateral ICD-10 code exists (I70.203).  Because a bilateral code exists for this condition, to separate unilateral 
codes should not have been billed. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 01924 have not been met. Therefore, we decided that the Plan does not have to pay for code 
01924 billed for date of service May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services provided from November 1, 2022, to 
November 29, 2022. 
 
You asked the Plan to pay for the dialysis services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if an ESRD claim includes ESAs, these must be 
reported with modifier JA or JB. 
 
We looked at the file and Medicare rules. The claim includes codes for ESA administration but does not report 
modifiers JA or JB. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis services 
provided from November 1, 2022, to November 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 22, 2022, to 
September 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted all of the required 
paperwork with this claim. The Plan denied your request. The Plan says the NOA you submitted has the wrong 
admit date on it.  The NOA needs to reflect the first period of care. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the NOA is not 
correct.  The NOA has an admit date of August 18, 2022. however, all of the claims have an admit date of 
August 22, 2022.  These documents need to match. Based on this information, we find that the Medicare rules 
for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from August 22, 2022, to September 20, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from January 9, 2023, to January 12, 
2023. 
 
You asked the Plan to pay for the home health services. You say that this claim was billed with the correct 
Type of Bill code. The Plan denied your request. The Plan says that you billed with an incorrect type of bill 
code 
 
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's sole rationale for denial is that you billed with an 
incorrect type of bill code.  However, the Plan has failed to explain what, exactly, is wrong with the code.  The 
Plan has failed to identify what the correct type of bill code should be for this service. The burden is on the 
Plan to show why its denial is correct.  By failing to provide this information, we find that the Plan has not met 
this burden. Therefore, we decided that the Plan has to pay for home health services provided from January 9, 
2023, to January 12, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator you purchased on January 6, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you were told this item was covered by 
insurance.  This machine is to help you leave your house without tanks and a cart. The Plan denied your 
request. The Plan says purchased oxygen equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. In this case, you purchased the oxygen 
concentrator at issue.  Neither Medicare nor your Plan covers purchased oxygen equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to 
pay for the oxygen concentrator you purchased on January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0117U for date of service 
November 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and should be 
paid. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include 
the required unique identifier. The Plan also says that you billed the wrong Place of Service code on the claim. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
In addition, Medicare rules say that, for lab services, the POS code must reflect the location in which the 
sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.This claim was 
billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory 
setting. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 0117U 
for date of service November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 51798-59-XE billed for date of service February 24, 
2023. 
 
You asked the Plan to pay for code 51798-59-XE. You say that this was a separate procedure and should be 
paid. The Plan denied your request. The Plan says this service was not billed correctly.  Modifiers 59 and XE 
cannot appear together. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier XE may be used in situations where you 
used modifier 59 previously. Modifier XE should be used instead of modifier 59. 
 
In this case, you billed both modifier XE and 59 on the same claim line.  This is not appropriate as these 
modifiers are mutually exclusive.  Only one of these modifiers should appear on a claim line. Therefore, we 
decided that the Plan does not have to pay for code 51798-59-XE billed for date of service February 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 17, 
2022.  
 You asked the Plan to pay for procedure code 76642. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 17, 2022.