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

 
We decided that the Plan has to make partial payment for the home health services. We decided that the Plan 
does not have to make partial payment for the home health services.  
 
You asked the Plan to make partial payment for the home health services provided from January 3, 2022, to 
January 5, 2022. You say that you feel that this claim was denied incorrectly. The Plan says that the NOA was 
not submitted timely, so no payment can be made. 
 
We decided that the Plan has to make partial payment for the home health services.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. It is noted that NOAs submitted untimely will have the payment reduced by 
the number of days past the From date divided by 30.  
 
In this case, the Plan indicates that the NOA was submitted 25 days after the From date on the claim. As such, 
payment should only be reduced by 25/30, or about 83%. Therefore, we decided that the Plan has to make 
partial payment for the home health services.  
 
We also decided that the Plan does not have to pay in full for the home health services. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. 
 
Since the NOA was not submitted within 5 days of the start of care, payment in full is not due on this claim. 
Therefore, we decided that the Plan does not have to pay in full for the home health services. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on July 29, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
are supported in the medical record. The Plan denied your request. The Plan says this claim is missing the 
necessary secondary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that one of a specified group of secondary diagnosis 
codes must be reported in addition to a primary diagnosis for ambulance transportation claims.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, this claim does not include one of the 
secondary diagnosis codes required for ambulance transportation claims. Therefore, we decided that the Plan 
does not have to pay for ambulance services (A0428, A0425) provided on July 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 8, 2022, 
through July 14, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay was 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 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 the inpatient admission was not medically necessary for this enrollee. Inpatient care 
is necessary when the patients signs and symptoms and general medical condition can only be managed safely 
in an acute inpatient setting, when the enrollee requires diagnostic studies in an inpatient setting, or if it is 
medically necessary for the enrollee to remain in the acute inpatient setting. The enrollee was admitted to a 
hospital that was not in-network.  At the time of admission, the enrollee was medically stable and could have 
been transferred to an in-network facility or observed 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 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 July 8, 2022, through July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Levqio injection, inclisiran, 1mg. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no description of why the enrollee. cannot self-inject and there is no attestation 
that a recent conversation regarding lifestyle modifications has occurred. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has a diagnosis of familial hypercholesterolemia. The record provided does 
not indicate that the enrollee's current regimen is insufficient to manage the enrollee's hyperlipidemia.The Food 
and Drug Administration 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Levqio injection, inclisiran, 1mg.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98941 billed for dates of service August 15, 
2022, to November 23, 2022. 
 
You asked the Plan to pay for procedure code 98941. The Plan denied your request. The Plan says payment for 
code 98941 is bundled into payment for code 98942. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 98941 is a column II code to column I code 98942 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 98941 billed for dates of service August 15, 2022, to 
November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11004-59 and 99223-57 rendered on June 
13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 11004-59 and 99223-57 remain 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  is "CPT 11004:  
Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external 
genitalia and perineum 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 11004, the 
procedure report describes a more comprehensive procedure. In this case, the orchidectomy was done in the 
same anatomical area as the debridement performed. In this case, debridement would be included in the 
orchidectomy, and would not be reported separately with modifier -59 distinct procedural service. In terms of 
CPT 99223, the procedure report only supports a problem focused history, and an expanded problem-focused 
examination. The medical decision making of moderate complexity. The level of service billed is not supported 
by the medical records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 11004-59 and 99223-57 rendered on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886 and 95907 rendered on September 
29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 95907, the 
testing performed was for pedicle screw testing. This is recognized as being coded for as a triggered 
electromyography (EMG) study. There was no indication that stimulation of the skin surface was done in order 
to have performed a traditional nerve conduction study (NCS). Rather, the only recordings performed were 
EMGs. This code is not supported. In terms of CPT 95886, it is not supported, as no NCS was actually 
performed during the procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95886 and 95907 rendered on September 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows slippage and spinal stenosis. The cause 
of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 Plan denied your request. The Plan says you do 
not meet the criteria for admission to an Inpatient Rehabilitation Facility. You cannot tolerate three hours a day 
of therapy five days a week, medical illnesses are stable, and you do not need a rehabilitation physician to 
monitor a program three times a week. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing identified with code 0012M for date of 
service November 30, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0012M is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the laboratory testing at issue was 
billed with code 0012M. This code is specifically not covered. Based on this information, we decided that 
Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory testing identified with code 0012M for date of service November 30, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for a SNF 
admission to allow the enrollee to continue working with therapies. The Plan denied your request. The Plan 
says the SNF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, the enrollee does not require skilled therapy services on a daily basis. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 8, 2022, 
through April 12, 2022, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis of A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
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 primary diagnosis code 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 documentation does not support the primary diagnosis of 
A41.9. Our physician reviewer found the provided records are incomplete. Only two daily notes are identified, 
though six days of services were reportedly provided. While the member does appear to have been treated for 
an infection, the records are insufficient to show that after evaluation, sepsis was the condition for which the 
member was primarily treated.  
 
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 April 8, 2022, through April 12, 2022, and billed with diagnosis 
code A41.9.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on July 14, 2022, through July 
17, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that Medicare rules for payment of this 
claim have not been met. 
 
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 record does not include any clinical documentation. The record 
also clearly indicates that the Plan used medical records to make their decision. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case the Plans denial has not been substantiated, so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the inpatient hospital services 
provided on July 14, 2022, through July 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (81518) provided on June 23, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (81518) 
provided on June 23, 2022.