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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the member had a stroke and still has paralysis on 
the left side. You say the member has not regained their strength and needs continued care. The Plan denied 
your request. The Plan says your request for approval of continued admission in a SNF does not meet the 
requirements for approval. 
 
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 at the time of admission, the member required skilled rehab services to improve 
function due to weakness and deconditioning.  There were no skilled nursing needs.   As of last covered day, 
the member did not require any skilled nursing or rehab services on a daily basis.  She was not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or self-care tasks.  The member did not require skilled therapy to establish a safe 
and effective maintenance program.  As a practical matter, the member did not require any skilled services on 
an inpatient basis, at a skilled level of care as of July 31, 2023. The member did not have any parental 
medications, complex wound care or nutrition given via a feeding tube.  The members function was at or near 
her prior level of function and she could be discharged to a lower level of care for further services.  As of July 
31, 2023, the member required custodial services.  
 
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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 21, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the 
member's primary care provider did not refer for services. The health Plan requires utilization of network 
providers when possible and available and requires authorization for certain services. No medical necessity for 
an out-of-network provider, such as an urgent or emergency situation, has been documented. There is no 
network deficiency for these services and alternate network providers were found. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC) (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator . You say that you have to go out to the 
supermarket and doctors appointments carrying the oxygen tank which is very large and too heavy. Your 
pulmonary doctor advised that you should get a portable concentrator oxygen tank. The Plan denied your 
request. The Plan says Medicare does not cover an additional oxygen concentrator for specific use outside of 
the home.  
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a home oxygen system, including a home concentrator and portable oxygen tank. 
a home oxygen system, including a home concentrator and portable oxygen tank serves the same purpose as a 
portable oxygen concentrator . Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (POC) (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds, but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The file shows that the enrollee weighs 260 pounds. 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 pre-approve a heavy duty extra wide hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear peripheral interpretation by physician with 
written report rendered on November 2, 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 billed service has been denied because it was reported with one or more diagnosis code pairs 
that are subject to an Excludes1 note. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 it is not appropriate to report 
D72.821: monocytosis (symptomatic), and D72.10: eosinophilia, unspecified together 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 blood smear peripheral interpretation by physician with written report rendered on November 2, 
2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 72125, 70486,74177, 
71260, 70496, 70498, 72170 and 73590. We decided that the Plan does not have to pay for the services 
described by procedure code(s) 70450.  
 
You asked the Plan to pay for the radiology services provided on March 2, 2023, billed with codes 70450, 
72125, 70486,74177, 71260, 70496, 70498, 72170 and 73590. . You say that this should be paid.  The Plan 
says that the denial was valid for these services. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 72125, 70486,74177, 
71260, 70496, 70498, 72170 and 73590.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 72125, 70486,74177, 71260, 
70496, 70498, 72170 and 73590.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
70450. 
 
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 70450 
is a column II code in relation to column I code 70496. 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 the services described by procedure code(s) 
70450. 
 
 
  
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the PuraPly XT skin substitute application. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the wound to the right ankle has been treated with a skin substitute within the last 
year. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that these services are necessary to avoid an expensive surgical procedure, and in accordance with the 
community standards 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve the PuraPly XT skin substitute application.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 rendered 
on March 8, 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 denied codes are not supported in the records submitted. 
 
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 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
CPT 96521: 
 
Refilling and maintenance of portable pump 
 
Healthcare Common Procedure Coding System (HCPCS) J1817: 
 
Insulin for administration through dme (i.e., insulin pump) per 50 units 
 
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 records include 
documentation outpatient intravenous insulin treatment (OIVIT). In this, there is a more appropriate code to 
report for these services. Therefore, the records do not support CPT 96365 and CPT 96366.  
 
In addition, in terms of CPT 96521 and J1817, neither refilling and maintenance of a portable pump, nor insulin 
for administration through durable medical equipment (DME) would be reported when OIVIT services are 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 96365, 96366, 96521, and J1817 rendered on March 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 30, 2022. 
 
You asked the Plan to pay for the services. You say that you are requesting reconsideration for services 
advising the coding department has reviewed the services and determined that the claim is coded correctly. The 
Plan denied your request. The Plan says M54.9 has an Excludes1 note with R52 so should not be reported 
together. 
 
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 the services. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. Per ICD 10 guidelines an excludes1 not exists with ICD 10 
R52 and M54.9. Which means, these two codes would not be reported together. Therefore, this procedure 
denied correctly. 
 
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 ambulance services provided on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 28, 2023. 
 
You asked the Plan to pay for the medical services. You say that this is an existing patient and you have 
provided medical records to support payment. The Plan denied your request. The Plan says you billed this 
claim with an inappropriate pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of J31.0 and J30.9. Code J31.0 is an Excludes1 code under 
code J30.9, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 11, 
2023.   
You asked the Plan to pay for procedure code 99285. You say that the charges were appropriate for the level of 
acuity required. The Plan denied your request. The Plan says payment for code 99285 is bundled into payment 
for code 99236. 
 
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 99236 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat or donut cushion. 
 
You asked the Plan to pre-approve these services. You say that you fell and fractured your tailbone. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve seat or donut cushion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic pathogen detection testing provided on February 
7, 2023, billed with multiple codes.  
 
You asked the Plan to pay for the testing as billed. You say that this should be paid.  The Plan denied your 
request. The Plan says this was not correctly billed.  
 
The Plan must follow Medicare rules. Medicare rules say that genetic pathogen testing must be billed with a 
single code and one unit of service regardless of the number of targets tested.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing as billed have not been met. Therefore, we decided that the Plan does not have to pay 
for the genetic pathogen detection testing provided on February 7, 2023, billed with multiple codes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 23, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the health plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider, 
such as an urgent or emergency situation, has been documented. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device. 
 
You asked the Plan to pre-approve a CPM device. You say that you need this device for therapy before you go 
back into rehab. The Plan denied your request. The Plan says CPM devices are not covered for rotator cuff 
surgery. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion (CPM) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator 
(0408T). 
 
You asked the Plan to pre-approve a heart assist device. You say that currently the enrollee is not responding to 
guideline directed medical therapy and has exhaust or failed all other conservative and standard of care 
treatments. The Plan denied your request. The Plan says this procedure is considered experimental, 
investigational and unproven. There is insufficient evidence of its safety and effectiveness.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is not enough medical proof that shows the safety and/or 
success of insertion of permanent cardiac contractility modulation system when used for heart failure. Based on 
this information, we decided that Medicare rules for coverage of a heart assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse 
generator (0408T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 
12-25 targets (87507) provided March 21, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please review the attached medical records 
to support medical necessity. The Plan denied your request. The Plan says this service does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or National Coverage 
Determination (NCD).  
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that enrollee presented to Urgent Care with 7 
days of diarrhea. The gastrointestinal PCR panel tested for 21 pathogens. Per the Per the LCD: Gastrointestinal 
pathogen (GIP) panels utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs), 12 or more 
targets, are medically reasonable and necessary for the evaluation of Medicare beneficiaries with the following: 
An immunocompromising medical condition with acute or persistent diarrhea. In this case, the enrollee did not 
have an immunocompromised medical condition. The review has determined that the items/services at issue in 
this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 12-25 targets (87507) 
provided March 21, 2023.