Persius/hicric huggingface dataset:
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 to return to being independent as 
quickly as possible. The Plan denied your request. The Plan says the services you need can be provided safely 
in other settings.  
 
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. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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. 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 procedure code 00104 billed for date of service October 6, 
2022.  
 
You asked the Plan to pay for procedure code 00104. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says payment for code 00104 is bundled into payment for code 
90870. 
 
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 00104 is a column II code to column I code 90870 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 00104 billed for date of service October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on October 
22, 2022. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on October 22, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper eyelid blepharoplasty. 
 
You asked the Plan to pre-approve an upper eyelid blepharoplasty. You say that you would see better if the 
skin was removed. The Plan denied your request. The Plan says this procedure would be considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an upper eyelid blepharoplasty. Our 
reviewer says that this surgery is not medically necessary. Our reviewer found clinical notes does document 
details of how enrollee's symptoms affect functional activities of daily living. Visual fields submitted did not 
show at minimum 12 degree of superior visual field. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upper eyelid blepharoplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an upper eyelid blepharoplasty.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that the enrollee would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says an IRF admission 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee's condition is in fact highly complex and fragile, and there is every reason to expect that 
she will participate in and benefit from services to include at minimum PT, OT, physician oversight of her 
various cardio, pulmonary, renal risk factors, and case manager coordination of any additional services that 
might be needed to make a sustainable return home, and avoid preventable re-admissions to the acute hospital. 
Therefore, the requested inpatient rehab facility admission is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E0973, E0973, E0961, E0961, E2611, 
E2601, E0978, E0971, and E0971 provided on December 19, 2022. 
 
You asked the Plan to pay for procedure codes E0973, E0973, E0961, E0961, E2611, E2601, E0978, E0971, 
and E0971. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says the documentation requirements have not been met. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for procedure codes E0973, E0973, E0961, E0961, E2611, E2601, 
E0978, E0971, and E0971 provided on December 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 27, 2022, to 
December 26, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA. 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 October 28, 2022. The NOA was not received by the Plan until February 
13, 2023. 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 home health services provided 
from November 27, 2022, to December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided on May 8, 2023. 
 
You asked the Plan to pay for procedure codes 96365 and 96366. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided 
on May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
February 15, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level, or that 75 minutes 
or more were spent on the service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 11, 2022. 
 
You asked the Plan to pay for the medical services. You say that this claim was coded correctly. The Plan 
denied your request. The Plan says you billed these services with an incorrect Place of Service code on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies billed for date of service January 30, 2023. 
 
You asked the Plan to pay for the medical supplies. You say that you have provided all required information. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, there is 
no packing slip clearly listing the items provided to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for medical supplies billed for date of service January 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of a new patient (99204), radiologic examination, swallowing function, with 
cineradiography/video radiography, including scout neck radiograph(s) and delayed image(s) (74230), 
radiologic examination, spine, cervical (72040), and radiologic examination, mandible (70100) provided on 
January 31, 2023. 
 
You asked the Plan to pay for the office visit or other outpatient visit, radiology exam of the neck, radiologic 
exam of the spine and cervical region and radiologic exam of the jawbone. You say that medical records submitted supports codes 74230, 72040, 70100, 99204 and should be paid. The Plan denied your request. The 
Plan says the POS 11 (office setting) was billed, however, documentation received does not support that the 
services were performed in an office or other outpatient setting but rather in a mobile setting at a SNF. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another POS code exists. For example, a mobile unit may 
be sent to a physician's office or a skilled nursing facility. If the mobile unit is serving an entity for which 
another POS code already exists, providers should use the POS code for that entity. However, if the mobile unit 
is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile 
Unit POS code 15.  
 
We looked at the file and Medicare rules. The records show that the enrollee received mobile radiology 
services at a nursing home. The POS code listed on the claim is for an office POS. There is no evidence these 
services were provided in the office setting. Therefore, we decided that the Plan does not have to pay for the 
office or other outpatient visit for the evaluation and management of a new patient (99204), radiologic 
examination, swallowing function, with cineradiography/video radiography, including scout neck radiograph(s) 
and delayed image(s) (74230), radiologic examination, spine, cervical (72040), and radiologic examination, 
mandible (70100) provided on January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with diagnosis codes R73.03 
and E11.9 provided on April 6, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes R73.03 and E11.9 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for the laboratory services billed with diagnosis codes R73.03 and E11.9 provided on April 6, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on October 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 99284 requires documentation to justify the level of care. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function."  
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation from that date 
describes the patient as tripping and falling, hitting his head, knees, and arm. The enrollee had no symptoms to 
report without report of loss of consciousness. The examination was relatively unremarkable except for 
abrasions and laceration to the head, knee, arm. The plan included laceration repair, Keflex (oral), and 
disposition home. The enrollee was labeled as stable. The provided documentation does support a detailed 
history and physical, however, it does not support medical decision making of moderate 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99284) rendered on October 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel provided on April 27, 2023, 
and billed with codes 87150, 87798, 87481, 87640, and 87653. 
 
You asked the Plan to pay for the urinary tract infection panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urinary tract infection panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection panel 
provided on April 27, 2023, and billed with codes 87150, 87798, 87481, 87640, and 87653.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 18, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnoses billed are payable. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that F13.939 has an Excludes1 note in relation to F13.2. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on March 18, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on December 31, 2021. 
 
You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says the claim was 
untimely, and the submission did not meet the exception criteria guidelines outlined in 42 CFR 424.44.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physical therapy was not filed until February 2, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physical therapy provided on December 31, 2021.