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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service February 28, 
2023. 
 You asked the Plan to pay for procedure code 76770. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 
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 76770 
is a column II code to column I code 93976. 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 76770 billed for date of service February 28, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip and thigh supports (E0956 x2) and hardware (E1028 
x2). 
 
You asked the Plan to pre-approve hip and thigh supports and hardware. The Plan denied your request. The 
Plan says it is not shown that additional hip and thigh supports are medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a positioning accessory (such as code E0956) is 
covered for a beneficiary who meets both of the criteria listed in the Medicare rules section of this letter. 
 
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 hip and thigh supports and hardware. 
Our reviewer says that this request is not medically necessary. Our physician reviewer found the enrollee has a 
hip fracture and history of clubbed feet. The enrollees condition does not require the use of additional leg and 
thigh rests.  
We looked at this physician's review, the file, and Medicare rules. Specifically, the enrollees diagnoses do not 
fall under either of the diagnosis code groups that represent significant postural asymmetries. Based on this 
information, we decided that Medicare rules for coverage of hip and thigh supports and hardware have not been 
met. Therefore, we decided that the Plan does not have to pre-approve hip and thigh supports (E0956 x2) and 
hardware (E1028 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor, 
including programing (33285).  
 
You asked the Plan to pre-approve the insertion of a subcutaneous cardiac rhythm monitor. You say that this 
service is medically necessary. The Plan denied your request. The Plan says the enrollee has no history of 
cryptogenic stroke or syncope.  
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria in the rules 
section 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 the insertion of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
that the patient has a history of atrial fibrillation. There is no documentation provided to suggest a history of 
unexplained syncope or any other apparent indication for an ILR. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollees 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 insertion of a subcutaneous cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac 
rhythm monitor, including programing (33285).
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 services are medically necessary due to the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee does not meet the 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96356, 96366 and 95621 billed for date of 
service April 11, 2023. 
 
You asked the Plan to pay for procedure codes 96356, 96366 and 95621. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these codes are 
not supported as the services provided would be better reported with a different code. 
 
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 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 96356, 96366 and 95621. Our reviewer says 
that these codes are not supported for the service provided. Our reviewer found the procedure report describes 
outpatient Nova R insulin infusion. In this case, there is a more appropriate code that should be reported for service provided.   
 
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 96356, 96366 and 95621 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 96356, 96366 and 95621 billed for date of 
service April 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 the services are medically necessary for the enrollee 
to regain their prior level of function. The Plan denied your request. The Plan says you can receive the care you 
need at a skilled nursing facility. 
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the goal is to promote strengthening back 
to a baseline functional status with a goal to discharge home or to a lower level of care. The Plan denied your 
request. The Plan says the enrollee can receive the care needed in another setting. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99496 and G8427 for date of service March 
7, 2023.  
You asked the Plan to pay for procedure codes 99496 and G8427. 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 TCM services are provided after the enrollee's 
inpatient discharge date. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue were for 
transitional care management (TCM) services. These services are provided in the enrollee's community setting. 
These codes were billed with place of service 21 (inpatient). As the services were not provided in the enrollees 
community setting, the claim is not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 99496 and G8427 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 99496 and G8427 for date of service March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
March 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. 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. 
 
The file shows that the enrollee received intravenous insulin therapy in an outpatient setting. We find that CPT 
code 96365 and 96366 is not supported. There is a more accurate code that describes the services provided. 
Also, an Outpatient Intravenous Insulin Therapy regimen is nationally non-covered under Medicare when 
furnished pursuant to an OIVIT regimen. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 96365 and 96366 billed for date of service March 22, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on July 25, 2022, to July 27, 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 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says that documentation 
does not support the billed codes. 
 
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 principal diagnosis code A41.9, described as sepsis, 
unspecified organism, and secondary diagnosis code J96.01, described as acute respiratory failure with 
hypoxia. 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 documentation does support the billed codes Our physician 
reviewer found that the enrollee had hypoxia requiring supplemental oxygen, with systemic inflammatory 
response syndrome and a pulmonary infiltrate, thus meeting criteria for pneumosepsis with respiratory failure, 
and satisfying diagnosis codes A41.9 and J96.01. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on July 25, 2022, to July 27, 2022, at the Diagnosis Related Group (DRG) originally 
billed.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57308 and related services and procedures 
provided on September 28, 2022. 
 
You asked the Plan to pay for procedure code 57308 and related services. 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. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 57308. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as inpatient only, and therefore must be billed as part of an inpatient admission. In this case, there is no 
indication that the enrollee was admitted as an inpatient for the provision of the service at issue. Therefore, we 
decided that the Plan does not have to pay for procedure code 57308 and related services and procedures 
provided on September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray billed with code 72040 for March 8, 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 claim was not billed with the correct place of service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an 
office setting but the documentation supports that the services were performed in a mobile unit in a skilled 
nursing facility. Therefore, we decided that the Plan does not have to pay for the x-ray billed with code 72040 
for March 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on August 2, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that there are no valid orders or records to support the 
billed HIPPS rate. 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 the home health services 
rendered on August 2, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic spine (72146) 
and an MRI of the lumbar spine (72148). 
 
You asked the Plan to pre-approve an MRI of the thoracic spine and an MRI of the lumbar spine. You say that 
the services are medically necessary. The Plan denied your request. The Plan says that there is no 
documentation of six weeks of conservative management. 
 
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 of the thoracic spine and an 
MRI of the lumbar spine. Our reviewer says that the requested services are medically necessary. Our physician 
reviewer found the enrollee has osteopenia, scoliosis and multiple compression fractures based on trauma and 
insufficiency. The notes indicate the enrollee is unable to go to physical therapy due to pain. While the 
neurology examination is normal the presence of this degree of compression fractures and the burning 
sensation it is reasonable to do an MRI of the thoracic and lumbar spine especially given the recent fall down 
the steps and multiple compression fractures due to the fall. 
 
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 of the thoracic spine and an MRI of the lumbar spine have been met. 
Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine (72146) and an MRI of the lumbar spine (72148).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 30, 2022, to 
September 28, 2022. 
 You asked the Plan to pay for the home health services. You say that it was unclear that the Plan was going to 
require NOAs. 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 August 30, 2022. The NOA was not received by the Plan until May 6, 
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 August 30, 2022, to September 28, 2022.
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 
March 16, 2023. 
 
You asked the Plan to pay for codes 96365, 96366, and 96521. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says these 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 96365, 96366, 96521 are not supported in the medical record. Specifically, for codes 
96365, 96366, and 96521, 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 there are more appropriate codes to be billed. Code J1817 represents Insulin for administration through DME (i.e., insulin pump) per 50 units. The medical 
records indicate Nova R was administered via intravenous treatment. This means there is a more appropriate 
code to be billed for the services rendered. 
 
Based on this information, we decided that Medicare rules for coverage of codes 96365, 96366, and 96521 
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 March 16, 2023.