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

 
We decided that the Plan does not have to pay for procedure code 99204 billed for January 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 99204 
provided on January 4, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99204 billed for 
January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interim crowns (D2799) for tooth #18 and #21. 
 
You asked the Plan to pre-approve the dental service. You say that the temporary crowns are an essential part 
of the dental treatment. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct because the temporary crowns are services included in the allowance of the permanent 
crowns. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
  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 dental service. Our reviewer says 
that the requested treatment of provisional crowns is not medically necessary. Our physician reviewer found 
that a separate charge for provisional crown or bridge is considered an integral part of the restorative process. 
The code requested is meant for situations where a final restoration cannot be completed without further 
diagnostics or additional treatment. In this case a standard bridge was being planned, which would include a 
temporary restoration as part of the procedure. 
 
The Plan requires that the code used for payment corresponds to the treatment provided. The codes used for 
provisional crowns are not appropriately used in this instance as a standard bridge is being planned which 
would include temporization as part of the procedure. No other diagnostics are required, or other treatment 
needed to be completed to justify a long-term provisional restoration such as that being requested. The 
requested treatment of provisional restorations does not meet plan criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the interim crowns (D2799) for tooth #18 and #21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says a BiPAP device with AVAPS would meet all the needs requested by 
the provider.  
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in intelligent 
volume assured pressure support (IVAPS) mode (for nocturnal and as needed daytime use) which is a modality 
that could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured 
pressure support (AVAPS) and a back-up rate. The provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. The provided records in this case do not provide adequate 
detailed information to meet Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with 
AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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. The Plan denied your request. The Plan says you do not meet the 
requirements. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 22, 2022, 
to December 27, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. 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 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 N17.0, defined as acute kidney failure with tubular 
necrosis. 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 documentation does not support the DRG billed. Our 
physician reviewer found the enrollee has a history of a traumatic brain injury. The enrollee presented with 
hydrocephalus who presented with severe sepsis and acute kidney injury from urinary tract infection. The 
enrollee had acute kidney injury, but the urinalysis does not show tubular casts; therefore, does not meet 
criteria for acute tubular necrosis.  
 
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 provided on December 22, 2022, to December 27, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99406 billed for March 22, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99406 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. Billed procedure code 99406 was billed on the same day as code 
99306 by a physician in the same group practice and is not separately payable. Therefore, we decided that the 
Plan does not have to pay for procedure code 99406 billed for March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 13, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81306, 81328 and 81335. 
 
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 
January 13, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81306, 81328 and 
81335.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's COPD is progressive and 
Irreversible, and it is essential you implement appropriate treatments to provide the enrollee with the best 
outcome, decrease healthcare utilization, and preserve his quality of life. The device is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of a ventilator. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, elevated 
hemidiaphragm, and uses narcotics chronically for pain. The enrollee was recently hospitalized with altered 
mental status and acute exacerbation of COPD. Arterial blood gas was consistent with acute on chronic 
hypercarbic respiratory failure. Recent spirometry was consistent with moderate to severe COPD. This enrollee 
may benefit from BiPAP with average volume assured pressure support (AVAPS) during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb 
volume management and moisture evacuation system (L5781) and an addition to lower limb prosthesis, vertical 
shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve lower limb prostheses. You say that the enrollee needs a prosthetic leg to 
walk. The Plan denied your request. The Plan says that the upgraded pylon is not medically needed. 
Experimental items and items that are not shown to be safe and effective cannot be covered. 
 
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. A request for information was sent to the Plan requesting medical records and 
they were not received. Therefore, we decided that the Plan has to pre-approve an addition to lower limb 
prosthesis, vacuum pump, residual limb volume management and moisture evacuation system (L5781) and an 
addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988).  
 
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: 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet all the requirements. Care is 
being provided in the current hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endovenous ablation therapy provided on January 19, 
2023, by an OON provider.  
 
You asked the Plan to pay for the ablation therapy. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the endovenous ablation therapy provided on 
January 19, 2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is necessary to increase 
the enrollee's mobility and allow for a good quality of life setting. The Plan denied your request. The Plan says 
that the enrollee's condition does not meet Medicare guidelines 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollees condition is in fact complex and fragile. There is every reason to expect that the 
enrollee will participate in and benefit from services to include physical therapy, occupational therapy, 
physician oversight of polypharmacy, and case manager coordination of any additional services that might be 
needed to permit the enrollee to return to their current living environment as well as avoid preventable 
admissions to the acute hospital. Moreover, the Plans assertion that the enrollee should be seeking care in a 
skilled nursing facility (SNF) seems to ignore the fact that she already receives a level of care comparable to a 
SNF in her assisted living facility, which is simply not meeting their functional rehabilitation 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
an 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 80053, 82040, 82247, 82310, 82374, 
82435, 82565, 82947, 84075, 84132, 84155, 84295, 84460, 84450, 84520, 85025, G0471, and P9603 billed for 
date of service February 7, 2023. 
 
You asked the Plan to pay for procedure code(s) 80053, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 
84075, 84132, 84155, 84295, 84460, 84450, 84520, 85025, G0471, and P9603. You say that you disagree with 
the denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing facility 
payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that the services were provided to the enrollee while a SNF inpatient. Per the Physician 
Fee Schedule, CPT codes 80053, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 
84295, 84460, 84450, 84520, 85025, G0471, and P9603 have a Professional/Technical indicator of 1. This 
means that CPT codes 80053, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 
84295, 84460, 84450, 84520, 85025, G0471, and P9603 have both a professional and technical component. In 
this case, CPT code 80053, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 
84460, 84450, 84520, 85025, G0471, and P9603 has not been billed with an appropriate modifier to indicate 
the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 80053, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 
84460, 84450, 84520, 85025, G0471, and P9603 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 80053, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 
84132, 84155, 84295, 84460, 84450, 84520, 85025, G0471, and P9603 billed for date of service February 7, 
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 the enrollee meets Medicare criteria for Acute 
Inpatient Rehab and will benefit from admission, that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says the enrollee's records do not that complex rehabilitation needs that require 
frequent evaluation by a rehabilitation doctor. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.