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

 
We decided that the Plan does not have to pre-approve five (5) home health physical therapy (PT) visits. 

You asked the Plan to pre-approve home health services. You say that the enrollee needs to continue to receive 
PT because she is still not able to be fully mobile and is still having difficulty with daily living tasks, toileting, 
bathing. The Plan denied your request. The Plan says the 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 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
returned home from a skilled facility stay. She was stand by assist to transfer and walk 75 feet. The enrollee 
had limited need for therapy at admission. She required a home exercise program. The record does not support 
continued need for unique input of 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five (5) home health physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9901 provided on March 1, 2023. 
 
You asked the Plan to pay for procedure code A9901. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for this service is bundled into 
payment for other related services. 
 
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 A9901 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A9901 is not in the statutory definition of "physician services" for fee schedule payment purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure code A9901 have not been 
met. Additionally, the Plan has reimbursed you the amount you paid for procedure code E1399 and you are not responsible for any further payment of code E1399. Therefore, we decided that the Plan does not have to pay for 
procedure code A9901 provided on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Signatera molecular residual disease (MRD) test. 
 
You asked the Plan to pre-approve the genetic testing. You say that this test determines if the cancer has 
returned, and you think it aids in your treatment The Plan denied your request. The Plan says at this time the 
current clinical role of this type of genetic testing remains uncertain, is considered investigational, and is not 
supported by the NCCN guidelines.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Signatera molecular residual disease (MRD) test.
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 are starting over with your new prosthetic and an 
IRF facility has the equipment and knowledge to help you walk again. The Plan denied your request. The Plan 
says you do not meet the criteria for admission to an IRF.  
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you 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 your functional status. You 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87498, 87502, 87634, U0003, and U0005) 
provided on December 23, 2022. 
 
You asked the Plan to pay for the panel testing. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  

We find that CPT codes 87498, 87502, 87634, U0003, and U0005 are not supported in the medical record. 
Specifically, a panel was performed and there is a more appropriate singular code for the services. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the panel testing (87498, 87502, 87634, U0003, and U0005) 
provided on December 23, 2022.
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 transfer to LTACH would be the 
appropriate level of care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
Health Plan. The 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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is not medically necessary. The Plan denied 
your request. The Plan says IRF care is necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical records significantly comply with the requirements for IRF admission. The patients 
condition is complex and fragile, and there is every reason to expect that the patient will participate in and 
benefit from services provided at an inpatient rehabilitation facility. Therefore, the requested inpatient 
rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraorifice barrier (D3911) provided on June 19, 2023. 
 
You asked the Plan to pay for D3911. You say that this was all part of a root canal. The Plan denied your 
request. The Plan says the denied dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraorifice barrier (D3911) provided on June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
May 15, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
May 15, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services coded as 71045-TC performed on May 19, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they are supported in the record and carriers do not require prior authorization for portable x-ray 
suppliers. The Plan denied your request. The Plan says that the radiology services are denied because the 
enrollee was inpatient at a Skilled Nursing Facility on the date of service. 
 
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 proof that the enrollee received the radiology services 
described by code 71045-TC during the course of a covered stay at the Skilled Nursing Facility, therefore we 
are unable to determine if the Plan was correct in denying the radiology services. Therefore, we decided that 
the Plan has to pay for the radiology services coded as 71045-TC performed on May 19, 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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code U0005. We decided that the Plan does not have to pay 
for procedure codes 87502, 87634, 87581, 87486, 87541, 87798, and 87640.  
 
You asked the Plan to pay for the lab testing billed for date of service March 1, 2023. You say that the results 
determine medical management and treatment decisions. The Plan says that one code must be submitted for the 
panel. 
 
We decided that the Plan has to pay for procedure code U0005.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The CPT Code Manual definition of code U0005 is infectious agent detection by nucleic acid; severe acute 
respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, 
making use of high throughput technologies, completed within 2 calendar days from date of specimen 
collection (list separately in addition to either code U0003 or U0004) as described by CMS-2020-01-R2. 
 
In this case, we have confirmed that code U0005 is an add-on code that has been billed with appropriate 
primary procedure code U0003, which the Plan has agreed to pay. The records show that the testing was billed 
within 2 days from the date of specimen collection. Based on the claim submitted, Medicare billing criteria 
have been met. Therefore, we decided that the Plan has to pay for procedure code U0005 billed for date of 
service March 1, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87502, 87634, 87581, 87486, 
87541, 87798, and 87640. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a respiratory panel was provided. We looked at the file and Medicare rules. This NGS panel 
was not billed with a single code as required. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87502, 87634, 87581, 87486, 87541, 87798, and 87640 billed for date of service March 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a dermatology/oncology consultation with an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an OON consult. You say that the enrollee needs to go to this office as their 
diagnosis is rare. You say that the enrollee has seen numerous dermatologists and oncologists with no resolve. 
You also say that the enrollee was referred to a facility that will not do surgery to remove cancer. The Plan 
denied your request. The Plan says that a network provider can care for your medical problem. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON consult. Our reviewer says that
the request for an OON consult is medically necessary. Our physician reviewer found the Plan's denial is not
medically justified on the basis that it is not offering adequate care to meet the enrollee's medical needs through
referral to a network provider

The reviewer found that the enrollee's condition is a rare oncologic disease involving blood cell transformation that would make it medically necessary for them to see the requested out-of-network provider. Therefore, the reviewer found that the request for an out-of-network consult is medically reasonable and necessary in this case.  

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 OON consult have been met. Therefore, we decided that the Plan has to pre-
approve a dermatology/oncology consultation with an out-of-network (OON) provider.  
 
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 genetic testing provided on June 24, 2022, billed with 
codes 81226, 81227, 81240, 81241, 81306, 81328, 81335, 81401, and 81406. 

You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 24, 2022, billed with codes 81226, 81227, 81240, 81241, 81306, 81328, 81335, 81401, and 81406.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 3, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that you would like the Plan to reconsider their 
denial of payment. 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 87798 is 13. The MAI value for this code is 3. You billed 19 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 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on July 5,
2023.

You asked the Plan to pay for the dental service. You say that you went to the dentist for a crown that came out
after a month and paid $80 to the provider who was out-of-network. You also say that you received a denial of
payment of $144 which you cannot afford to pay. The Plan denied your request. The Plan says your benefit for
the re-cement or re-bond crown has already been exhausted

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record
shows your benefit for the re-cement or re-bond crown was exhausted on date of service April 11, 2023.
Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided
on July 5, 2023.