Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external patient provided on January 17, 2023. 
 
You asked the Plan to pay for external patient. You say that the services should be covered. 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 external patient provided 
on January 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with DRG 193 rendered 
from December 17, 2022, to December 22, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 193. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee has a history of chronic obstructive pulmonary disease (COPD) who was admitted with 
bilateral pneumonia and treated with nasal canula oxygen as well as intravenous antibiotics, respiratory 
treatments and corticosteroids. An arterial blood gas at admission showed a pO2 of 46 on room air without 
acidosis or hypercarbia. Baseline blood gases were not provided. The need for invasive or non-invasive 
mechanical ventilation was not documented. The enrollee was discharged on oral antibiotics after medical 
therapy in the hospital. Overall the records support the diagnosis of pneumonia with chronic obstructive 
pulmonary disease (COPD) exacerbation but not J96.01 - acute respiratory failure with hypoxia. Based on the 
medical records provided, DRG 194 most accurately reflects the enrollee's condition and treatment in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with DRG 193 rendered from December 17, 2022, to December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration for the 
denied payment. 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 laboratory services 
provided on April 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (J3420, J3411, J3415, J1955, 96372) provided 
on September 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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. Medicare rules also say that prolotherapy is not 
covered by Medicare. If prolotherapy is billed using a trigger point therapy code, it will be considered not 
reasonable and necessary.  
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 use of codes J3420, 
J3411, J3415, and J1955, is not supported by the records provided. Our reviewer found that when medications 
are mixed they become a compounded drug, which would be reported with a more appropriate HCPCS code, 
and compounding sheet. Compounded drugs are not separately reported. 
 
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. 
 
Additionally, in this case, prolotherapy was billed using trigger point therapy codes. Per L37635, this is not 
medically reasonable and necessary, and as such, is not covered. Therefore, we decided that the Plan does not 
have to pay for the services (J3420, J3411, J3415, J1955, 96372) provided on September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complex functional impairments have mostly resolved. The enrollee's 
documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 22, 2023, billed with 
procedure codes 96365-59 and 96366-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 96365-59 and 96366-59 is intravenous infusion, for 
therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, and intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in 
addition to code for primary procedure). 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found there is a more specific code to report for 
service provided.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 22, 2023, billed with procedure codes 
96365-59 and 96366-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 4, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 4, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335 and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on October 5, 2022, billed with 
procedure codes 36620 and 76937-26. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 36220 and 76937-26 is arterial catheterization or 
cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous, and ultrasound 
guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of 
selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent 
recording and reporting (List separately in addition to code for primary procedure).  
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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found Procedure code 36620 denied correctly as 
this procedure was not described in the medical record submitted. Procedure code 76937 is an add-on code that 
denied correctly as documentation submitted does not include a valid primary 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 the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on October 5, 2022, billed with procedure codes 36620 
and 76937-26.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health occupational therapy services. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented, ongoing, home health occupational therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health occupational therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 12, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that an implantable loop recorder is a 
necessity for your care. The Plan denied your request. The Plan says an implantable loop recorder is 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 an implantable loop recorder. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an ILR. There is insufficient documentation to 
support the medical necessity for insertion of an ILR in your 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implantable loop recorder (33285).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac catheterization procedure (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that cardiac catheterization is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says cardiac catheterization is 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 cardiac catheterization. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had a negative stress test in 2021 and a negative stress test in June of 
2023. The left ventricular ejection fraction is normal at 55% to 60%. The provided documentation does not 
reveal the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac catheterization procedure (93458).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
December 5, 2022, and billed with codes 87481, 87500, 87640, 87652, 87798, 87899, and 87900. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this test 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 urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on December 5, 2022, and billed with codes 87481, 87500, 87640, 87652, 87798, 87899, and 87900.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84165) provided on December 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim was submitted with an incorrect 
place of service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that for services provided to a patient who is registered inpatient or outpatient of a hospital, the 
correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS 
code or that of the appropriate outpatient hospital POS code.  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 medical records label this enrollee as 
inpatient status at the time of services. This means that reporting POS code 22 (On Campus-Outpatient 
Hospital) is not appropriate in this case, as an inpatient POS code would be necessary. Therefore, we decided 
that the Plan does not have to pay for laboratory services (84165) provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 31, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 a home visit provided on 
March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) machine. 
 
You asked the Plan to pre-approve continued use of CPAP. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CPAP is only covered for certain indications. 
 
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 continued use of CPAP. Our reviewer 
says that the documentation does not support that the requested device is medically reasonable or necessary. 
Our physician reviewer found you have a diagnosis of obstructive sleep apnea and is troubled with cough at 
night. You report difficulty with using CPAP because of the cough. Compliance data covering April 1 through 
July 11, 2023, showed 28% of days with at least four hours of use. This does not meet Medicare criteria. The 
records do not include a clinical visit to address the cough or CPAP compliance issues. Since you are not able 
to use the device enough for effectiveness, it is considered 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 continued use of CPAP have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) machine.