Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies billed with codes E2103 and A4239 for date of 
service June 19, 2023. 
 
You asked the Plan to pay for codes E2103 and A4239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the signature on the proof of delivery is not legible and does not note the name of the designee on 
the delivery slip. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for supplies billed with codes E2103 
and A4239 for date of service June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 22, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if the enrollee receives services not covered by the Plan or services obtained out-of-network and 
were not authorized, the services are not covered. 
 
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 the services provided on May 22, 2023, by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vitamin B12 and levocarnitine. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lower extremity 
neuropathy. The Food and Drug Adminstration (FDA) has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Vitamin B12 and levocarnitine injections are therefore not 
reasonable or medically necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. 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 Vitamin B12 and levocarnitine.
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 admission to LTACH is required to meet 
the current needs and can be managed safely while receiving physical therapy and occupational therapy. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to a Long-Term Acute Care Hospital. 
 
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 enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time.  
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services billed for dates of service 
September 26, 2022, and October 5, 2022. 
 
You asked the Plan to pay for the billed services. 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 shows that the services at issue were reimbursed by the Plan 
on January 23, 2023. A comparison of claims shows these are exact duplicates. There is no evidence to support 
that the billed services were provided twice on the same date. Based on this information, we decided that the 
Medicare rules for the billed services have not been met. Therefore, we decided that the Plan does not have to 
pay for the physical therapy services billed for dates of service September 26, 2022, and October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 12, 2022, billed with 
codes 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that the panel testing guides the appropriate 
treatment choice. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. The panel testing was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 12, 
2022, billed with codes 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, and 81194.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 93313 and 00562. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 99100. 
 
You asked the Plan to pay for codes 93313, 00562, and 99100 billed on date of service May 23, 2023. You say 
that 93313, 00562, and 99100 should be paid as billed because they are supported in the medical record. The 
Plan says that 93313 and 00562 are being handled as an original decision reopen for New and Material 
Evidence, therefore no coverage decision has been made. 99100 is considered bundled and is not separately 
payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 93313 and 00562.  
 
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) 93313 and 00562.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate procedure code.  
 
We looked at the file and Medicare rules. We find that procedure code 99100 has a status indicator of B on the 
Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 99100 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 99100. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service April 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that the physician sends specimens for testing. The 
Plan denied your request. The Plan says the billed services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. In this case, there are no lab results from the billing provider for the 
for the tests at issue. There is no documentation to show that the lab at issue performed the testing in this case. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing billed for date of service April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87556, 87641, 87798) provided 
on June 29, 2022. 
 
You asked the Plan to pay for lab services. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid 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 87481, 87500, 87556, 87641, & 87798 are not supported in the medical record. 
Specifically, multiple unbundled codes were billed for a single panel. Based on this information, we decided 
that Medicare rules for coverage of lab services have not been met. Therefore, we decided that the Plan does 
not have to pay for lab services (87481, 87500, 87556, 87641, 87798) provided on June 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 12, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the diagnoses billed are correct. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R06.82 has an Excludes1 note in relation to R06.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have 
to pay for ambulance services provided on June 12, 2023.
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 enrollee is needed to continue IV 
antibiotic therapy and returning home is currently not a safe environment. The Plan denied your request. The 
Plan says continued care needs for the enrollee include completing antibiotics, weekly labs, wound checks, and 
wound care at the current hospital facility. 
 
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 enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time.  
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 25, 2021, 
to July 27, 2021. 
 
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 medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met.Our physician reviewer found 
the enrollee had a mechanical fall that needed evaluation and was at risk for an adverse event if she was to fall 
again. The records do not support a reasonable expectation that, at the time of the inpatient admission, the 
enrollee's hospital care would span two midnights. The inpatient level of care was therefore not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from July 25, 2021, to July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99418 billed for date of service April 11, 
2023. 
 
You asked the Plan to pay for procedure code 99418. You say that this is an add-on code and should be paid 
based on the time of services provided. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 99418 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99418 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99418 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99418 billed for date of service April 11, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services provided on June 14, 2023. 
 You asked the Plan to pay for the therapy services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F01.50. This code 
is not an appropriate primary diagnosis as the code has a code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for therapy services provided on June 14, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70546 billed for date of service June 19, 
2023.  
 You asked the Plan to pay for procedure code 70546. You say that CPT code 70546 was billed correctly and 
should be paid. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 70546 is 1 unit. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided. The file includes two imaging reports; however, these reports are identical for imaging 
performed at 2:02PM. Based on this information, we decided that Medicare rules for coverage of procedure 
code 70546 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
70546 billed for date of service June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endovascular revascularization/atherectomy with 
angioplasty (37229). 
 
You asked the Plan to pre-approve the surgical service. You say that this is medically necessary. The Plan 
denied your request. The Plan says this procedure has not been shown to improve health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical service. Our reviewer says 
that the requested endovascular revascularization/atherectomy with angioplasty is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has 
chronic venous insufficiency with dopplerable pedal pulses and normal ankle-brachial indices by arterial 
duplex examination. The record indicates that the enrollee has undergone treatment of the left leg. The record provided does not establish the presence of a hemodynamically atherosclerotic obstructive lesion, the failure of 
conservative therapy including smoking cessation and exercise program, or the evidence of limb threatening 
ischemia. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. Therefore, the reviewer found that the requested endovascular 
revascularization/atherectomy with angioplasty is not considered medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an endovascular revascularization/atherectomy with angioplasty (37229).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 8, 2022, to 
November 9, 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 medical 
documentation provided supports principal diagnosis code I50.33 was billed correctly. The Plan denied your 
request. The Plan says after a thorough review of all the information in the submitted medical record, the 
review did not find sufficient documentation to clinically validate the diagnosis of I50.33. 
 
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 I50.33, Acute on chronic 
diastolic (congestive) heart failure. 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 physician reviewer found the documentation supports 
chronic heart failure and not a diagnosis of acute-on-chronic heart failure. There was no documentation of 
symptoms, studies, labs to suggest an acute component to her heart failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 8, 2022, to November 9, 2022, at the Diagnosis Related 
Group (DRG) originally billed.