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

 
We decided that the Plan does not have to pay for the laboratory panel provided on December 13, 2022, billed 
with codes G2023, U0003, U0005, 87502, 87634, 87581, 87486, 87541 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that these services were necessary and are 
supported in the medical record. 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 a 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 a laboratory panel that was not billed with a single panel 
code as required. In addition, there is no documentation of direct specimen collection for severe acute 
respiratory syndrome. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on December 13, 2022, billed with codes G2023, U0003, U0005, 87502, 87634, 87581, 87486, 
87541 and 87798.
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 November 29, 
2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that HHAs must report where home health services 
were provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim does not report where home health 
services were provided with a required Q code. Therefore, we decided that the Plan does not have to pay for 
home health services billed for date of service November 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on November 16, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says there is no documentation that transportation by ground 
ambulance would have endangered the enrollee's health. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air transport was not medically necessary. Our physician reviewer found the enrollee was being 
treated for chest pain. The enrollee was found to have an abdominal aortic aneurysm (AAA), which appeared to 
be increasing in size. Vascular services were not available locally, and the enrollee was appropriately 
transferred for vascular services. However, given the proximity of the sending and receiving hospitals, it does 
not appear that the use of an air ambulance was medically necessary or reasonable. The enrollee could have 
been transported via an appropriate ground ambulance without posing an additional risk to their condition. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services provided on November 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from April 11, 2023, to May 10, 2023. 
 You asked the Plan to pay for SNF care. You say that the services the enrollee required and received were 
necessary and coverable. The Plan denied your request. The Plan says the enrollee did not meet SNF criteria.  
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 pay for SNF care provided from April 11, 2023, to May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service May 18, 
2023. 
 You asked the Plan to pay for procedure code 64488. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 64488 is bundled into payment for code 19370. 
 
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 64488 
is a column II code to column I code 19370. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 64488 billed for date of service May 18, 2023.
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 has complex medical needs 
and requires ongoing acute care. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for LTACH services. 
 
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 the enrollee is receiving appropriate care in the current acute care setting 
provided by the 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported removable upper 
denture (D6110). 
 
You asked the Plan to pre-approve the dental services. You say that this is necessary. The Plan denied your 
request. The Plan says your benefit for the requested item or service 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 Plans 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 requested item or service was exhausted on date of service June 2, 2023. Therefore, 
we decided that the Plan does not have to pre-approve an implant/abutment supported removable upper denture 
(D6110).
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 would like more intense therapy than is usually 
available in a nursing home environment. The Plan denied your request. The Plan says admission to an IRF 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program? There is not a reasonable expectation 
that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 04, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were appropriately billed and should be 
paid. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 04, 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirments 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required can be provided 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 29, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were not properly billed. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612). 
 
You asked the Plan to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar. 
You say that this is medically necessary. The Plan denied your request. The Plan says the Medicare criteria for 
reasonable and necessary are not met because use of these devices as a stand-alone procedure has not been 
shown to be safe and effective in long term studies. These devices are not approved for use in a stand-alone 
procedure as requested. 
 
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 arthrodesis, posterior or posterolateral 
technique, single interspace; lumbar. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the Minuteman device is 
experimental for spine surgery and back pain. There is no spinal instability. Fusion is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, posterior or posterolateral technique, single interspace; lumbar have 
not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99223 for date of service 
September 20, 2022, to September 21, 2022. 
 
You asked the Plan to pay for procedure codes 99233 and 99223. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99233 and 99223 are not supported in the medical record. Specifically, the submitted 
medical records do not include a subsequent hospital care evaluation and management note for the billed date 
of service; therefore, code 99233 cannot be verified. The submitted medical records do not include an initial 
hospital care evaluation and management note for the billed date of service; therefore, code 99223 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 99233 and 99223 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99233 
and 99223 for date of service September 20, 2022, to September 21, 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 services are medically necessary for 
the enrollee to receive continuation of care for their complex medical needs that require ongoing acute 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 the enrollee appears to still be unstable for transfer and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current 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 pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and 
placement of transfixing device (27279) 
 
You asked the Plan to pre-approve percutaneous/minimally invasive sacroiliac joint fusion. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not medically necessary because the 
records show that the enrollee has many other potential causes of the lower back pain. 
 
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 percutaneous/minimally invasive 
sacroiliac joint fusion. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident 
regarding imaging or radiographic evidence supporting a sacroiliitis pathology. There is no clear history of 
sacroiliac joint pain onset or failure of conservative treatment directed to the sacroiliac joint. Multiple other 
plausible pain generators including at the lumbosacral spine are evident. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous/minimally invasive sacroiliac joint fusion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or 
minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when 
performed, and placement of transfixing device (27279)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant neuroelectrodes (63650 x2). 
 
You asked the Plan to pre-approve implant neuroelectrodes. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is lack of most recent imaging. There is no documentation from the 
surgeon to show that this patient is not a surgical candidate. Also, the patient has not had an ongoing 
psychological counseling and evaluation for a trial of neuromodulation therapy.  
The Plan follows Medicare rules. Medicare rules say that implantation of stimulators can be covered under 
specific conditions. 
 
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 implant neuroelectrodes. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no recent magnetic 
resonance imaging of the thoracic and lumbar spine. This is required before placement of a spinal cord 
stimulator trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implant neuroelectrodes have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implant neuroelectrodes (63650 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 for date of service January 18, 2023. 
 
You asked the Plan to pay for procedure code 87506. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
 
 We find that CPT code 87506 is not supported in the medical record. Specifically, the documentation shows 
that a comprehensive diarrhea panel of 26 pathogens was performed. There is a more appropriate code to be 
billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87506 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87506 for date of service January 18, 2023.