Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 3, 2023, to February 1, 
2023. 
 
You asked the Plan to pay for the home health services. You say that the NOA has been submitted to the Plan. 
The Plan denied your request. The Plan says that the NOA was not received timely. As such, this final claim 
was correctly denied. 
 
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 has not provided evidence showing the date they received 
your NOA. There is no evidence showing your NOA submission was late. Therefore, we decided that the Plan 
has to pay for the home health services provided from January 3, 2023, to February 1, 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 pneumatic compression device provided on September 
14, 2022, to September 26, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
equipment used in a facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 14, 2022, to September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 15, 2022, to 
November 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 15, 2022, to 
November 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service January 30, 
2023.  
 
You asked the Plan to pay for procedure code 88291. You say that you disagree with the denial. 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 88291 is 1. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88291 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88291 billed for date of service January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 27, 
2023.  
 
You asked the Plan to pay for procedure code 99458. You say that the claim 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 99458 is two (2). The MAI value for this code is 3. You billed five (5) 
units of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess 
units were actually provided, were correctly coded, and were medically necessary. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 27, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the cytopathology (88120) provided on January 26, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the enrollee's diagnosis does not support the medical necessity of the service provided.  
 
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. The Plan did not provide medical documentation to verify if the services are 
supported. Therefore, we decided that the Plan has to pay for the cytopathology (88120) provided on January 
26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an OON office visit. You say that you have been seeing this provider for many 
years. The Plan denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that authorization rules 
apply for out-of-network physician/practitioner services, including office visits. 
 
We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, 
we decided that Medicare rules for coverage of an OON office visit have not been met. Therefore, we decided 
that the Plan does not have to pay for an office visit provided on January 31, 2023, by an out-of-network 
(OON) provider.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for the outpatient hospital services, except for codes 33947 and 33954, 
billed for November 11, 2022. We decided that the Plan does not have to pay for procedure codes 33947 and 
33594. 
 
You asked the Plan to pay for the critical care services, extracorporeal membrane oxygenation (ECMO) 
therapy billed with codes 33947 and 33954, and laboratory services rendered on November 11, 2022. You say 
that you disagree with the denial. The Plan says that the services were not billed correctly. 
 
We decided that the Plan has to pay for the outpatient hospital services, except for codes 33947 and 
33954.   
 
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. The Plan states that the enrollee was incorrectly billed as an inpatient claim and 
that the enrollee was not admitted as inpatient; however, the claim shows that type of bill code 131 was billed 
for outpatient hospital. There is no documentation to support that the claim was submitted as an inpatient claim.  
Therefore, we decided that the Plan has to pay for the outpatient hospital services, except for codes 33947 and 
33954, billed for November 11, 2022. 
 
We also decided that the Plan does not have to pay for the ECMO billed with codes 33947 and 33954. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure codes 33947 and 33954 have an OPPS status 
indicator of C, meaning they are inpatient-only codes that are not paid at the outpatient rate. Therefore, we 
decided that the Plan does not have to pay for procedure codes 33947 and 33954 billed for November 11, 2022 
 
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: Partially Favorable

 
We decided that the Plan has to pre-approve four home skilled nursing visits. We also decided that the Plan 
does not have to pre-approve three home physical therapy visits and three home occupational therapy visits.  
 
You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We decided that the Plan has to pre-approve four home skilled nursing visits.  
 
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 home health skilled nursing visits. Our 
reviewer says that the services are medically reasonable and necessary. Our physician reviewer found that the 
enrollee would benefit from the additional home health nursing care visits for oversight of her medication 
management and diabetes mellitus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits have been met. Therefore, we decided that the 
Plan has to pre-approve four skilled nursing visits.  
 
We also decided that the Plan does not have to pre-approve three home physical therapy visits and three 
home occupational therapy visits. 
 
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 home health therapy visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found that 
the enrollee has caregiver assistance and her progress with therapies has plateaued. The enrollee does not 
require multiple skilled therapies and the assistance/supervision is not required to be provided by a skilled 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled therapy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve three home physical therapy visits and three home occupational 
therapy visits. 
 
 
 
 
 
 
 
 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 a CxBladder testing (0012M) provided on October 24, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that the combination of the medical records and 
strong peer-reviewed publications along with the support of Novitas/CMS LCD coverage is sufficient evidence 
to rule in your favor and provide payment for this claim. The Plan denied your request. The Plan says the 
requested testing is not covered. 
 
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. The requested testing is not covered by Medicare or the Plan. Based 
on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. 
Therefore, we decided that the Plan does not have to pay for a CxBladder testing (0012M) provided on October 
24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 14, 
2022, to August 15, 2022. 
 You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically 
necessary at the acute level of care. You also say that you would like the denial to be overturned. The Plan 
denied your request. The Plan says the information received does not support that criterion were met for 
inpatient hospitalization. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from August 14, 2022, to August 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99496 and G8427 billed for February 24, 
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. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was not under inpatient status for the 
date of service at issue and the claim was incorrectly billed with the POS code 21 for inpatient hospital. Therefore, we decided that the Plan does not have to pay for procedure codes 99496 and G8427 billed for 
February 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization (37225-RT) provided on October 5, 
2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 37225 is revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same 
vessel, when performed. 
 
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 service. Our reviewer found the medical records provided show there is no support that code 37225-RT is the most accurate code for the service 
provided. Code 37227 appears to be the most accurate CPT code for the service provided in this case. 
 
We looked at this physician reviewer's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan 
does not have to pay for the revascularization (37225-RT) provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service October 17, 
2022.  
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the denial. 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 99233 is 1. 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, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 billed for date of service October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix to be provided by an out-of-network provider. 
 You asked the Plan to pre-approve Epifix. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
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 Epifix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a chronic pressure wound. Epifix is supported by studies for the management 
of venous and arterial wounds. However, the enrollee has a chronic decubitus pressure which is not supported 
by sufficient high-quality evidence to recommend its use for this clinical situation at this time. Therefore, the 
enrollee does not meet criteria for the requested 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 Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled-nursing facility care provided from November 21, 
2022, to November 30, 2022. 
 
You asked the Plan to pay for skilled-nursing facility care. 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. Medicare rules say that the HIPPS code is structured differently, as a 
result of there being five case-mix adjusted rate components. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of skilled-nursing facility care have not been met. Specifically, the services at issue have been 
incorrectly reported with a four-character HIPPS code. A full HIPPS code should comprise five characters. 
Therefore, we decided that the Plan does not have to pay for skilled-nursing facility care provided from 
November 21, 2022, to November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the barium swallow study (74240, 74230 and 92611) 
provided on March 15, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The services are not a covered benefit as it is listed under the Limitations 
and Exclusions section for code billed on date of service March 15, 2022. The documentation supports the 
studies represented by the procedure codes were performed at a nursing home (via mobile van/portable x-ray) 
which are denied as an excluded place of service. In addition, the POS 11 is not supported. Per Medicare 
Claims Processing Manual, when services are furnished in a mobile unit, they are often provided to serve an 
entity for which another POS code exists. For example, a mobile unit may be sent to a physicians office or a 
skilled nursing facility. If the mobile unit is serving an entity for which another POS code already exists, 
providers should use the POS code for that entity. However, if the mobile unit is not serving an entity which 
could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. Therefore, 
we decided that the Plan does not have to pay for the barium swallow study (74240, 74230 and 92611) 
provided on March 15, 2022.