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

 
We decided that the Plan does not have to pay for the lab panel provided on May 12, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
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. The lab panel in this case was billed with multiple codes, and not one 
unit of one code as required by LCA A58761. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on May 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary and all of your providers 
agree that this is something you need. The Plan denied your request. The Plan says you do not have any acute 
medical needs that require direct physician oversight.  
 
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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not have a need for acute rehabilitation level of 
care at this time.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical needs are not adequately being 
met or managed at home with home health. The Plan denied your request. The Plan says the enrollee's records 
do not show the need for frequent evaluation by a rehabilitation physician or the need of the intensity of 
three hours of daily therapies. The Plan says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve craniofacial neurostimulation via peripheral nerve 
stimulator. 
 
You asked the Plan to pre-approve craniofacial neurostimulation via peripheral nerve stimulator. You say that 
craniofacial neurostimulation via peripheral nerve stimulator is medically necessary. The Plan denied your 
request. The Plan says craniofacial neurostimulation via peripheral nerve stimulator is considered experimental. 
 
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 craniofacial neurostimulation via 
peripheral nerve stimulator. Our reviewer says that the requested craniofacial neurostimulation via peripheral 
nerve stimulator is not considered medically reasonable and necessary. Our physician reviewer found in this 
case, the record indicates that you have facial postherpetic neuralgia. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of craniofacial neurostimulation via peripheral nerve stimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve craniofacial neurostimulation via peripheral 
nerve stimulator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76360 billed for date of service June 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says that the enrollee has not met the deductible. 
 
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 73630 is payable in this case. The enrollees Plan contract does not show that the 
enrollee has a deductible. The enrollee also does not have a copay for outpatient diagnostic tests. Based on this 
information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan 
has to pay for procedure code 76360 billed for date of service June 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the inpatient decompression L2-3 laminectomy (63407, 
22612, 22840x2).  
 
You asked the Plan to pre-approve the inpatient laminectomy. You say that the enrollee would benefit from an 
L2-3 decompression laminectomy.  The Plan denied your request. The Plan says the laminectomy is not 
medically necessary. The Plan says the enrollee has not done any physical therapy and declined an epidural 
steroid.  
 
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 the inpatient laminectomy. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case.  
 Our physician reviewer found more conservative measures for back pain are needed, including a six-week trial 
of physical therapy. Also, a laminectomy does not need inpatient stay as a 48-hour observational stay is 
appropriate.  
 
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 inpatient laminectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve  the inpatient decompression L2-3 laminectomy (63407, 22612, 22840x2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for date of service June 6, 2023. 
 
You asked the Plan to pay for the home health services. You say that this claim was billed correctly, and you 
are an in-network provider. The Plan denied your request. The Plan says you billed this claim with the wrong 
Type of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a Plan of Treatment 
should be billed with Type of Bill 032x.  The 4th digit should be one of the following: 7 (to indicate a 
replacement claim), 8 (to indicate a voided or cancelled claim), or 9 (to indicate a final claim). 
 
In this case, the claim at issue appears to be a final claim, so the Type of Bill code should have bill 0329.  
However, you have billed code 0323, which is not correct. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services billed for date of service June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a hospital bed. You say that it is in the enrollee's best interest to have a 
hospital bed to help with their peripheral edema. The Plan denied your request. The Plan says the 
documentation does not support that the enrollee meets the Medicare criteria. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is noted to have venous insufficiency and a pressure wound of the buttock. 
However, there is very limited clinical history and physical examination findings as well as the enrollees level 
of mobility and function. The enrollee is noted to have a pressure wound, but the documentation does not 
indicate that the enrollee is unable to re-position themself while in bed and requires frequent re-positioning or 
an immediate change in position, which is required for a semi-electric hospital bed versus a standard hospital 
bed. There is also no documentation indicating that this cannot be accomplished in an ordinary bed. Therefore, 
the requested semi-electric hospital bed (E0260) is 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 hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a semi electric hospital bed (E0260).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29530 billed for June 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 procedure code 29530 is not supported when billed with 97530 and 97110. 
 
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 29530 is strapping of knee. 
 
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 these services. Our reviewer says that procedure code 29530 
is not supported when billed with 97530 and 97110. Our reviewer found the records do not support that code 
29530 was a separate and distinct procedure from the provided therapeutic activities. No modifier was used 
with the billing to indicate that the strapping was a separate and distinct 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 29530 billed for June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 12, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination.  
 
We looked at the file and Medicare rules. The testing provided in this case is not covered under the MolDx 
program. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 12, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Resolve MDx for Urinary Tract Infection (UTI) testing 
provided on November 30, 2022. 
 
You asked the Plan to pay for Resolve MDx for UTI testing. You say that this test was necessary and 
appropriate. The Plan denied your request. The Plan says this test was not medically necessary. 
 
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 Resolve MDx for UTI testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the degree of testing provided was neither reasonable nor 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 Resolve MDx for UTI testing have not been met. Therefore, we decided that the 
Plan does not have to pay for Resolve MDx for Urinary Tract Infection (UTI) testing provided on November 
30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a BVN. 
 
You asked the Plan to pre-approve a BVN. You say that the requested procedure will help the enrollee achieve 
better pain control and functional improvement. The Plan denied your request. The Plan says the procedure 
requested does not meet the requirements for approval. 
 
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 BVN. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested service is considered an experimental/ investigational procedure. 
 
 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 BVN have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a BVN.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left and right cardiac catheterization. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has dyspnea on exertion. 
He had a recent radionuclide stress test which was negative for ischemia. The rationale for this invasive study 
is not clear. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time 
cardiac catheterization would not be considered medically appropriate and necessary in the enrollee's clinical 
management.  
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve left and right cardiac catheterization.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that you are requesting reconsideration so you may 
help facilitate care for the enrollee. The Plan denied your request. The Plan says the records do not show the 
enrollee meets criteria for the requested PET/CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 a PET/CT scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found as the cancer treatment occurred over six 
years ago, a routine surveillance PET scan to look for recurrence is unnecessary and not medically necessary at 
this point. 
 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan (78815).
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 all treatment teams feel the enrollee is medically 
appropriate for inpatient rehabilitation. You say the enrollee will be most successful at this level of care given 
their prior level of function and current diagnosis. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical or occupational therapy, at an 
intensive rehabilitation therapy program. 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. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement; however, the documentation doesnt support that they meet criteria for admission to an acute 
inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an 
IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 
three visits weekly to regain or maintain their functional status. The enrollee can receive further services at a 
lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.