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

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 16, 
2023.  
 
You asked the Plan to pay for procedure code 81456. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87640, 87651, 87798, U0004 and U0005) provided on January 26, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this testing 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 laboratory services have not been met. Specifically, the records show that this was a single panel 
which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to 
pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798, U0004 
and U0005) provided on January 26, 2023.
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 member would benefit from being 
closely monitored by nursing staff that can be provided in a LTAC setting. The Plan denied your request. The 
Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: 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 inpatient rehab cannot be accomplished at a lower 
level of care. The Plan denied your request. The Plan says an admission into an inpatient rehabilitation facility 
is not medically 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that because you are missing toes, you catch my 
toes and foot on things and fall as you have no feeling in your feet to be able to balance properly. You also say 
that you have had several heart surgeries and cannot walk long distances, which is why you feel this should be 
covered. The Plan denied your request. The Plan says Medicare's medical necessity criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power scooter. Our reviewer says that 
you do not meet the coverage criteria for a power scooter. Our physician reviewer found the documentation 
available for review does not support that you require a power mobility device to accomplish mobility related 
self-care tasks in the home. Our reviewer also found that there is no indication you are unable to use an 
alternative assistive 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77300 billed for date of service May 10, 
2023.   
You asked the Plan to pay for procedure code 77300. 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 77300 is 10. The MAI value for this code is 3. You billed 18 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 77300 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 77300 billed for date of service May 10, 2023.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the request for LTACH 
services is not medically necessary.  
 
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 the current acute care setting as provided 
by the 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: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric services provided on July 28, 2022, to 
November 13, 2022.  
 
You asked the Plan to pay for the inpatient psychiatric services. You say that the enrollee was admitted for 
competency restoration services. You say that the records provided support the need for the services in dispute.  
The Plan denied your request. The Plan says the enrollee self-directed out-of-network.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 psychiatric services. Our 
reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the provided 
records in this case do not document any notation from the treating physician that the enrollee was not stable 
for transfer to an in-network psychiatric facility on any dates of service. Given that the enrollee was transferred 
to the hospital on July 28, 2022, from a local jail (presumably with the involvement of law enforcement and/or 
corrections officers), records support that the enrollee would have been stable to transfer (under those same 
conditions) to an in-network psychiatric facility on that same date and 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 inpatient psychiatric services have not been met. Therefore, we decided that 
the Plan does not have to pay for inpatient psychiatric services provided on July 28, 2022, to November 13, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with a Licensed Mental Health 
Counselor (LMHC).  
 
You asked the Plan to pre-approve a continuation of care with an LMHC. You say that you have been seeing 
this provider for over 6 years and have built a good relationship with her while overcoming many challenges.  
The Plan denied your request. The Plan says the requested provider is not considered a qualified mental health 
care professional allowed by Medicare.  
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules also say that Mental Health Counselors are not eligible to 
enroll in Medicare.  
 
Review of the file and Medicare records indicates that the provider at issue is a Mental Health Counselor and is 
not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve a 
continuation of care with a Licensed Mental Health Counselor (LMHC).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be safely discharged home. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you need the 
power scooter because you have torn meniscus on your knees, arthritis on your lower knees, and you are unable 
to walk far. The Plan denied your request. The Plan says you do not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 group 1 standard power operated 
vehicle. Our physician reviewer found you have obesity and osteoarthritis. You have normal gait and 
coordination, and are able to walk long distances with a cane. Our reviewer also found that you do not require a 
power wheelchair or scooter to perform MRADLs. 
 
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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient care provided from September 9, 2022, to September 14, 
2022. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says that the billed 
DRG is not supported. 
 
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 argues that the billed DRG is not supported. However, the Plan has not 
provided medical records supporting its denial. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the inpatient care provided from September 9, 
2022, to September 14, 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 procedure code 88341 billed for date of service September 
14, 2022.   
You asked the Plan to pay for procedure code 88341. You say that this service was medically necessary. 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 88341 is 13. The MAI value for this code is 3. You billed 23 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service September 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 27, 2022, to 
August 25, 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
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. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 27, 2022. The NOA was not received by the Plan until October 5, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from July 27, 2022, to August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 23, 2021, billed with 
codes 81201, 81295, 81298, 81317, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
July 23, 2021, billed with codes 81201, 81295, 81298, 81317, and 81406.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DecisionDx-Melanoma testing. 
 
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 molecular diagnostic testing for melanoma is 
covered when specific criteria are met. 
 
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 malignant melanoma 
on the trunk with a documented pathologic stage of pT1a Nx Mx. The records do not contain documentation of 
concern for errors in staging. The records do not support that the criteria for coverage are met and that the 
testing is reasonable and medically necessary for the enrollee. 
 
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 DecisionDx-Melanoma testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has improved their glucose control 
on this medication. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mounjaro.