Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric services provided February 14, 2023, to 
February 28, 2023. 
 
You asked the Plan to pay for the inpatient psychiatric services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that there is not an approve authorization for the dates of 
service billed, rendered services and facility provider. 
 
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. We find that the documentation has conflicting information. The documentation 
states that the Plan has denied this claim due to payment is not allowed for this service because the service 
dates do not match the number of units billed. No additional documentation to support this statement has been 
provided. In addition, the documentation states that the Plan has denied this claim also due to there is not an 
approve authorization for the dates of service billed, rendered services, and facility provider. The Plan also 
states that there was an authorization number that approved dates of service February 14, 2023, to February 17, 
2023, and February 21, 2023, to March 20, 2023. The documentation did not include explanation on why these 
approved dates were not paid by the Plan. Additionally, no medical records were provided to review whether 
the services were medically necessary or not. No other denial rationale was provided. The Plan did not 
substantiate their denial. Therefore, we decided that the Plan has to pay for the inpatient psychiatric services 
provided February 14, 2023, to February 28, 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 services provided on April 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the office setting POS code. 
The records do not support that the services were provided in an office setting. Therefore, we decided that the 
Plan does not have to pay for the services provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6251 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for procedure code A6251. The Plan denied your request. The Plan says the code is 
bundled into payment for other services. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A6251 has a Status Indicator of P on the Physician Fee Schedule. This means that 
procedure code A6251 is not separately payable. 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 procedure code 
A6251 billed for date of service January 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95816-24 billed for date of service 
October 3, 2022. 
 
You asked the Plan to pay for procedure code(s) 95816-24. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this code is included in the facility payment and is 
not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95816-24. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 95816-24. Based on this 
information, we decided that Medicare rules for coverage of procedure code 95816-24 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 95816-24 billed for date of 
service October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Aortopathy Comprehensive Panel (81410, 81411) 
provided on July 18, 2023. 
 
You asked the Plan to pay for the Invitae Aortopathy Comprehensive Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says these codes are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure codes 81410 and 81411 are unlikely to 
impact therapeutic decision-making in clinical management of the patient and will be denied as not medically 
necessary. 
 
We looked at the file and Medicare rules. This information shows that the codes at issue are not covered. 
Therefore, we decided that the Plan does not have to pay for the Invitae Aortopathy Comprehensive Panel 
(81410, 81411) provided on July 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a selective catheter placement (procedure code 36245) 
performed on July 7, 2023. 
 
You asked the Plan to pay for a selective catheter placement (procedure code 36245). You say that procedure 
code 36245 is appropriate based on the services performed. The Plan denied your request. The Plan says the 
records do not support the services at issue in this case. 
 
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 36245 is selective catheter placement, arterial system; 
each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family. 
 
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 a selective catheter placement (procedure code 36245). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found procedure report does not include documentation of selective catheter placement, arterial system; each 
first order abdominal, pelvic, or lower extremity artery branch. This procedure was not found in medical 
record.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a selective catheter placement (procedure code 36245) have not been met. 
Therefore, we decided that the Plan does not have to pay for a selective catheter placement (procedure code 
36245) performed on July 7, 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 admission is a medical necessity. The Plan denied 
your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility services you are 
requesting do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee with pelvic fractures does not meet Medicare coverage criteria for IRF 
admission. The enrollee is medically stable and does not need a physical medicine and rehabilitation 
physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing needs are documented. At the 
current functional level, the enrollee needs minimal physical therapy and occupational therapy. The enrollee 
does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The document does not support necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) does not require 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The 
enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a 
skilled nursing 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 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 does not meet the requirement for IRF 
services. The Plan denied your request. The Plan says the enrollee is requesting an IRF admission as he has a 
lot of medical conditions.  
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
December 12, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 urine polymerase chain reaction (PCR) 
panel rendered on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on May 17, 2023. 
 
You asked the Plan to pay for the panel. 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 a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
unit of one code as required by LCA A58720. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on May 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transportation rendered on August 4, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 26, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the 
same date. Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent transportation rendered on 
August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) and a comprehensive assessment and 
care planning (G0506) provided on June 21, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a comprehensive assessment. You say that you were the only 
provider available to do the service. You are requesting reprocessing of the claim for payment. The Plan denied 
your request. The Plan says the requested provider does not work with the enrollee's health plan. The Plan also 
says non-urgent services should be from network providers who are contracted with the Plan and listed in the 
provider directory. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) and a comprehensive 
assessment and care planning (G0506) provided on June 21, 2023, by an out-of-network (OON) provider.
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 additional rehabilitation due to the muscles 
in your throat not working which causes recurring aspiration pneumonia. The Plan denied your request. The 
Plan says you do not meet the requirements for a LTACH 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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. 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 and/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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 10061 and 20240 performed on March 14, 
2021. 
 
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. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that CPT 
code 10061 is not supported. The record states that the complex abscess was on the right heal [sic] and the 
excisional debridement was also performed on the right heal [sic]. The incision and drainage is not a separate 
procedure and is part of the debridement.  

Additionally, CPT code 20240 is not supported. The biopsies were reported for the 4th and 5th metatarsals. The 
record states that excisional debridement to the bone was performed at these sites, which includes excision of 
bone that is sent for pathology. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 10061 and 20240 performed on March 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under the Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 29, 2023, billed with 
procedure code 99458. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this add-on code cannot be billed by itself. 
 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 99458 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for practitioner services provided on June 29, 2023, billed with procedure code 99458.
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 still requires physical and occupational 
therapy to rebuild and regain their strength. 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.