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

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for February 1, 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same date of 
service as minor surgical procedure 64490. Payment for code J3490 is included in the global surgical payment 
for code J3490. Therefore, we decided that the Plan does not have to pay for the drug services billed with code 
J3490 for February 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care (99232) 
provided on January 25, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital inpatient or observation care have not been met. Specifically, the claim has been reported with diagnosis codes E11.621 and E08.621. These codes are marked with an Excludes1 note, 
indicating that the codes should not be reported together. Therefore, we decided that the Plan does not have to 
pay for subsequent hospital inpatient or observation care (99232) provided on January 25, 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. The Plan denied your request. The Plan says the enrollee does not 
require intensive nursing services. Services needed may be provided safely in 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that long term acute care is the only option 
for a safe discharge for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet all 
the requirements. Services needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99214 for January 26, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that follow-up services are included in the global surgical 
package.  
 
We looked at the file and Medicare rules. Procedure code 99214 was billed within 90 days of major surgical 
procedure 15933 billed on December 28, 2022. The -25 modifier is not supported as an unrelated service. 
Payment for code 99214 is included in the global surgical payment for 15933. Therefore, we decided that the 
Plan does not have to pay for the office visit billed with code 99214 for January 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service November 6, 
2022 to November 27, 2022. 
 
You asked the Plan to pay for procedure code S9338. You say that the patient's medication was authorized, so 
this claim should be paid. 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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service November 6, 2022 to November 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid swing and stance phase control (L5828), fluid 
stance extension (L5848), microprocessor control feature (L5856), flex-walk system or equal (L5981), multi-
axial rotation unit (L5986), and stance flexion feature (L5845). 
 
You asked the Plan to pre-approve a fluid swing and stance phase control, fluid stance extension, 
microprocessor control feature, flex-walk system or equal, multi-axial rotation unit, and stance flexion feature. 
The Plan denied your request. The Plan says the notes do not show why your current K3 foot and K3 knee, 
which are less than 2 years old, and therefore under warranty, need to be replaced. The Plan also says there is 
no documented physiologic change requiring new prosthetic foot or new prosthetic knee; no irreparable change 
to the foot or knee is documented; no documentation of repairs for the foot or knee is documented. 
 
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 a fluid swing and stance phase control, 
fluid stance extension, microprocessor control feature, flex-walk system or equal, multi-axial rotation unit, and 
stance flexion feature. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the physician documentation does not 
reveal clear documentation why the L5845 stance flexion feature is needed, therefore, the coverage criteria for 
this item has not been met. The enrollee's current knee and foot are under warranty. Our reviewer found that 
there is no evidence that the current knee and foot require repair. The physician documentation does not 
support why the enrollee's current foot and knee cannot be used for the enrollees functional needs. There is no 
change in the enrollees residual limb that requires a new prosthetic knee and foot. Our physician reviewer also 
found that the requested fluid swing and stance phase control (L5828), fluid stance extension (L5848), 
microprocessor control feature (L5856), flex-walk system or equal (L5981), and multi-axial rotation unit 
(L5986) are not 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 a fluid swing and stance phase control, fluid stance extension, microprocessor 
control feature, flex-walk system or equal, multi-axial rotation unit, and stance flexion feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a fluid swing and stance phase control 
(L5828), fluid stance extension (L5848), microprocessor control feature (L5856), flex-walk system or equal 
(L5981), multi-axial rotation unit (L5986), and stance flexion feature (L5845).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99213) rendered on October 
27, 2022. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT) code 99213 remains 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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 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 visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the vitals were not documented. The 
examination was focused and revelated systolic murmur. The provided documentation did not support a 
medically appropriate examination without vitals, did not support, did support a low level of decision-making, 
but did not support 20-29 minutes were spent (duration not documented).  
 
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 visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99213) rendered on October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need additional therapy, is a high risk for falling 
and needs more help to get back to the way before entering the hospital. The Plan denied your request. The 
Plan says you do not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 22 or more classes (G0483) provided on 
December 13, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 22 or more classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says that this service is not a covered benefit. 
 
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. In this case the Plan denied coverage stating that this testing is not a covered 
benefit. The plan-referenced Local Coverage Determination (LCD): Urine Drug Testing (L36037) does not 
indicate non-coverage for this service. The provider has correctly billed for the drug testing of 22 or more 
classes. Therefore, we decided that the Plan has to pay for the definitive drug testing of 22 or more classes 
(G0483) provided on December 13, 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: 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 Long-Term Acute Care Hospital 
admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee can 
remain in the current acute care location until such time no further acute level care is needed. Services needed 
may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti (Q5117). 
 
You asked the Plan to pre-approve Kanjinti. You say that this medication is medically necessary to treat the 
enrollee's condition. The Plan denied your request. The Plan says medication dispensed by a pharmacy is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Kanjinti (Q5117).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on July 15, 2022, to July 
16, 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 the 
medical records support payment of the DRG originally billed. The Plan denied your request. The Plan says the 
billed principal diagnosis of A41.9 (Sepsis, unspecified organism) is not supported by the medical record. The 
principal diagnosis should have been J18.9 (pneumonia, unspecified organism). 
 
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 a principal diagnosis of A41.9 (Sepsis, unspecified 
organism). 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 reviewer says that the billed principal diagnosis of A41.9 (Sepsis, unspecified 
organism) is not supported by the medical record. Our physician reviewer found the patient is a 71-year-old 
female who presented to the emergency room with shortness of breath, was diagnosed with pneumonia and 
chronic obstructive pulmonary disease (COPD) exacerbation following initial workup and was started on fluids 
and antibiotics. Her vitals were stable except for tachycardia. She did not have abnormal lab values. There was 
insufficient evidence of a life-threatening organ dysfunction directly related to a dysregulated response to 
infection to meet Sepsis 3 criteria. Therefore, the code, A41.9 (sepsis) is not sufficiently supported for this 
admission.   
 
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 July 15, 2022, to July 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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 meets the criteria for admission.  The 
Plan denied your request. The Plan says the records do not show the enrollee is willing or able to participate in 
the intensity of three hours of daily therapies provided in the IRF setting. Services needed may be provided 
safely in 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS Oral Brush CDx Biopsy test provided on March 
3, 2022.  
 
You asked the Plan to pay for the WATS Oral Brush CDx Biopsy test. You say that this test is recommended in 
the standard of practice guideline of major medical societies. The Plan denied your request. The Plan says the 
clinical value and effectiveness of this test in the setting of an unchanged oral lesion has not been demonstrated 
in the peer-reviewed literature.  
 
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 WATS Oral Brush CDx Biopsy test. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the provided records in this case do not document necessity of the test 
as opposed to an evaluation with a standard biopsy.  
 
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 WATS Oral Brush CDx Biopsy test have not been met. Therefore, we 
decided that the Plan does not have to pay for the WATS Oral Brush CDx Biopsy test provided on March 3, 
2022.