Persius/hicric huggingface dataset:
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's medical management and rehabilitation 
needs require and inpatient rehabilitation stay with close physician supervision. The Plan denied your request. 
The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of 
care.  
 
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 do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician. Although the enrollee continues to have a need 
for skilled therapy, the documentation does not support that they would meet criteria for admission to an acute 
inpatient rehabilitation facility. The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets IRF admission criteria 
under Centers for Medicare & Medicaid Services (CMS) guidelines. The Plan denied your request. The Plan 
says based on Medicare guidelines, the IRF services requested 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
does not support that he would meet criteria for admission to an acute IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain his functional status.  The 
enrollee can receive further services at a lower 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: Favorable

 
We decided that the Plan has to pay for the services provided on December 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Plan has not provided documentation showing 
that these services were previously paid on another claim. 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 pay for the services 
provided on December 30, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service May 30, 
2023. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says procedure code 36000 is considered bundled and not 
separately payable.  
 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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's medical needs. The Plan denied your request. The Plan says the records recieved show that there is 
no need for an intensive rehabilitation program.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 29, 2023, to June 
30, 2023. 
 
You asked the Plan to pay for home health services. You say that you are a valid network provider for the 
services at issue. The Plan denied your request. The Plan says rules for payment for home health services have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that TOB is a required data element. This 4-digit 
alphanumeric code gives two pieces of information. The first three digits indicate the base type of bill. The 
fourth digit indicates the sequence of this bill in this particular period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the services at issue have been reported with 
an invalid TOB. Therefore, we decided that the Plan does not have to pay for home health services provided 
from June 29, 2023, to June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A5500-RT, KX and A5514-RT, KX 
provided on June 27, 2023. 
 
You asked the Plan to pay for procedure codes A5500-RT, KX and A5514-RT, KX. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 
not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that the diabetic inserts for the right foot were billed with one diagnosis code that was inappropriately coded. Medicare rules say that some ICD-10-CM codes 
indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.  
 
In this case, diagnosis code L97.525 is described as non-pressure chronic ulcer of other part of left foot with 
muscle involvement without evidence of necrosis. This diagnosis code specifies the left foot. The procedure 
codes that denied for payment were billed with a modifier, RT, indicating the items were for the right foot. The 
provider incorrectly pointed to diagnosis code L97.525 for the items provided for the right foot. The provider 
should include diagnosis code L97.515, which specifies the right foot, and have the denied codes (A5500-RT 
and A5514-RT) for the right foot point to the correct diagnosis code. The Plan will accept a corrected claim 
from the provider. Please note, you are not responsible for the denied charges. If the provider sends a corrected 
claim that the Plan approves, you may be responsible for any applicable cost share applied. Therefore, we 
decided that the Plan does not have to pay for procedure codes A5500-RT, KX and A5514-RT, KX provided 
on June 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs  inpatient rehabilitation, physical 
and occupational therapy. The Plan denied your request. The Plan says the enrollee's condition does not meet 
all of the requirements for inpatient rehabilitation admission. The Plan says services may be provided at a 
lower level of care.  
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's functional 
level does not require treatment by multiple therapies including physical or occupational therapy in an intensive 
rehabilitation program in an IRF. While the enrollee may benefit from additional therapy the documentation 
does not support  that this is required to be in an IRF.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulator (TENS) device 
(E0730) provided September 23, 2023. 
 
You asked the Plan to pay for the TENS device. You say that the treatment provided was medically necessary 
and the physician has provided a statement of medical necessity and you submit medical records to justify the 
reason. The Plan denied your request. The Plan says these services are not covered per Medicare NCD. 
 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. Transcutaneous Electric Nerve Stimulation (TENS) units and 
garments and supplies for chronic back/neck pain/radiculopathy are not a Medicare covered benefit. Based on 
this information, we decided that Medicare rules for coverage of the TENS device have not been met. 
Therefore, we decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulator 
(TENS) device (E0730) provided September 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is medically unstable for transfer to an LTACH. 
 
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 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 the current acute care setting as provided 
by the Plan. The provided 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service January 30, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not supported. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
support that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of code G0483 have not been met. Therefore, we decided that the Plan does not have to pay for code 
G0483 for date of service January 30, 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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the current acute care setting being 
provided by the Health 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided in another setting such as a 
skilled nursing facility, home with home health services, or home with outpatient therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the ambulance services 
are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to 
independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay. The Common 
Working File (CWF) performs reject edits to incoming claims from independent suppliers of ambulance 
services.  
 
We looked at the file and Medicare rules. The ambulance services in this case were provided during an 
inpatient admission. As such, the ambulance services are bundled into the inpatient rate, and are not separately 
payable. 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 the ambulance services provided on May 18, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 12, 2023. 
 
You asked the Plan to pay for dental services. You say that you were unaware this dentist was suspended. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 
We looked at the file and Medicare rules. This provider has been precluded from participation in the Medicare 
program and is therefore not payable. Based on this information, we decided that Medicare rules for coverage 
of dental services have not been met. Therefore, we decided that the Plan does not have to pay for dental 
services provided on June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) billed for date of service 
April 14, 2023. 
 
You asked the Plan to pay for presumptive drug testing. You say that this service was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this service cannot be claimed, as 
another code from the 80305-80307 code range has already been reported and paid for this enrollee and date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that only one code from the 80305-80307 code range 
may be reported per date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of presumptive drug testing have not been met. Specifically, code 80305 was billed by another 
provider for this same enrollee and date of service. Therefore, we decided that the Plan does not have to pay for 
presumptive drug testing (80307) billed for date of service April 14, 2023.