Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says  the enrollee does not meet Medicare guidelines for 
services in 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 that the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 billed for February 20, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 11042 
provided on February 20, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99308 billed for 
February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87640, 87641, 87653, and 
87798) provided on November 14, 2022. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel (87481, 87640, 87641, 87653, and 87798) provided on November 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporarily implanted nitinol device (iTind) 
procedure (55899), and cystourethroscopy (C9769). 
 
You asked the Plan to pre-approve iTind procedure and cystourethroscopy. You say that this is medically 
necessary. The Plan denied your request. The Plan says not medically necessary. A review of the current 
medical literature does not consider this service to be standard medical treatment for the enrollee's condition. 
 
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 iTind procedure and cystourethroscopy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the use of a temporarily implanted nitinol device (iTind) is considered 
investigational as a treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Further 
studies are needed to evaluate the durability of iTind outcomes over a longer follow-up, to better define the 
indications of this approach, and to demonstrate the advantages of second-generation device over the first 
device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of iTind procedure and cystourethroscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a temporarily implanted nitinol device (iTind) procedure 
(55899), and cystourethroscopy (C9769).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has failed at multiple admission at lower 
levels of care due to their multiple medical and therapy needs. You say that IRF services are required to 
continue the frequent medical/physician oversight.  The Plan denied your request. The Plan says the enrollee 
does not meet all the requirements 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute 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, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided 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 an IRF admission and services.
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 the LTACH services. You say that the enrollee meets LTACH admission 
criteria and, due to wound care needs, is not a candidate for a lower level of care. 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 that there are no specific therapies that would be offered at the LTACH that are not 
currently being offered at the acute care hospital. 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
March 2, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 
81328, 81335 and 81479.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service October 23, 2021. 
 
You asked the Plan to pay for code 99285. You say that you disagree with the Plan's down-coding of 99285 to 
99284. The Plan denied your request. The Plan says code 99285 was not supported by the medical record 
because the patient's presenting problem was not a high/immediate threat to lift. Therefore, this code was 
down-coded to 99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity.  
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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the patient was a 65 year old woman with a history of 
chronic kidney disease who presented with abdominal and flank pain. The medical documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service October 23, 2021.
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 these services are medically necessary.  
The Plan denied your request. The Plan says the enrollee is currently receiving the appropriate 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 the medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. 
 
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 procedure codes 99284 and 27520 billed for December 29, 
2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 27520 is closed treatment of patellar fracture, without 
manipulation. 
 
We find that CPT code 27520 is not supported in the medical record. Specifically, the records do not support 
that fracture are was performed. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. Procedure code 99284 is within the global surgery period of code 
27520 provided on December 29, 2022. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99284 and 27520 billed for 
December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92025, 99203, 92020, 92201, 92286, 76512-
RT, and 76512-LT provided on December 20, 2021. 
 
You asked the Plan to pay for procedure codes 92025, 99203, 92020, 92201, 92286, 76512-RT, and 76512-LT. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says they are secondary to the enrollee's primary insurer. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for procedure 
codes 92025, 99203, 92020, 92201, 92286, 76512-RT, and 76512-LT until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for procedure codes 92025, 
99203, 92020, 92201, 92286, 76512-RT, and 76512-LT provided on December 20, 2021.
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 due to the complexity of the enrollee's status, nursing 
and medical management, in addition to therapy needs from multiple disciplines, an inpatient rehabilitation 
hospital level of care is warranted over what is available at a nursing home or lesser level of care. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 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. While the 
medical record supports a need for physical and/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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full charged amount for emergency services provided outside 
of the United States on February 9, 2023. 
 
You asked the Plan to pay the full charged amount for emergency services. You say that you should be 
reimbursed the full amount you paid. The Plan denied your request. The Plan says the Plan has paid the 
allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that with limited exceptions, items and services 
furnished outside the United States are excluded from coverage. While the Plan offers an additional benefit for 
worldwide emergency services, the Plan will only reimburse up to the Medicare allowable rates. 
 
We looked at the file and Medicare rules. The record shows that the Plan has paid the Medicare allowable 
amount for the service at issue. Therefore, we decided that the Plan does not have to pay the full charged 
amount for emergency services provided outside of the United States on February 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 12, 2022 
to September 14, 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 this 
service was medically necessary and correctly billed. The Plan denied your request. The Plan says DRG 192 
more accurately describes the services at issue. 
 
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 DRG 189. 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 records do not support the original DRG billed. Our physician reviewer found the clinical 
documentation does not support objective, definite evidence of pulmonary edema.  
 
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 September 12, 2022 to September 14, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95865 and 95870 for date of service January 30, 2023. 
 
You asked the Plan to pay for codes 95865 and 95870. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the codes are not payable 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 code 95865 is not supported in the medical record. Specifically, the submitted medical 
records do not include sufficient detail to support that needle electromyography; larynx, was performed; 
therefore, code 95865 cannot be verified. In this case, we have confirmed that code 95870 is a column II code 
to column I code 95865 This claim has not been billed with an appropriate modifier to bypass the edit. Based 
on this information, we decided that Medicare rules for coverage of codes 95865 and 95870 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 95865 and 95870 for date of service January 
30, 2023.