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

 
We decided that the Plan does not have to pay for an emergency department evaluation and management 
(E&M) visit provided on May 31, 2022. 
 
You asked the Plan to pay for emergency department E&M service. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says an additional unit of this code is not medically 
necessary. 
 
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 99285-25 is emergency department visit for the 
evaluation and management of a patient. 
 
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 emergency department E&M service. Our reviewer says that 
this code does not meet criteria for payment. Our reviewer found the record includes two copies of an evaluation and management service provided on the same date of service, at the same time, by the same 
provider. A remittance advice indicates code 99285 was paid. The additional unit of service for this procedure 
code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency department E&M service have not been met. Therefore, we decided 
that the Plan does not have to pay for an emergency department evaluation and management (E&M) visit 
provided on May 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on January 10, 2021. 
 
You asked the Plan to pay for the coronavirus test. You say that the claim should be reprocessed for payment 
based on the current federal guidelines for coronavirus testing and reimbursement. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus test (U0003) provided on January 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device identified with code 
E0676, pneumatic compressor identified with code E0652, and a segmental pneumatic appliance identified 
with code E0667. 
 
You asked the Plan to pre-approve a pneumatic compression device, pneumatic compressor, and a segmental 
pneumatic appliance. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the requested items are not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also state that a 
PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or 
abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an 
E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is 
required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. In addition, the record does not show that the enrollee 
had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-
person fitting, training and supervision by a technician who is skilled in and who regularly and successfully 
uses the appliance provided. 
 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device identified 
with code E0676, pneumatic compressor identified with code E0652, and a segmental pneumatic appliance 
identified with code E0667.
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 device is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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. 
 
 
 
 
 
 
 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 provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in 
the Local Coverage Determination (L33800): Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service should be paid. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
March 24, 2021. 
 
You asked the Plan to pay for the hospital discharge day management. You say that the initial charges were 
submitted in a timely manner. You also say that you would like this claim to be reconsidered and processed for 
payment. The Plan denied your request. The Plan says this claim was untimely, and the submission did not 
meet the exception criteria guidelines. 
 
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 hospital discharge day management was not filed until August 3, 2022. 
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 the hospital discharge day management (99238) 
provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service August 30, 
2021. 
 
You asked the Plan to pay for procedure code S2900. You say that this should be paid. The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service August 30, 2021.
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 services are medically necessary. The Plan 
denied your request. The Plan says the services you need can be provided safely in other settings, for example, 
a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical lab pathology provided on June 30, 2022. 
 
You asked the Plan to pay for surgical lab pathology. You say that you do not see the patient and it is up to the 
providers office to get paperwork. 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). there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for surgical lab pathology 
provided on June 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of abdominal aorta (76706) provided on 
October 6, 2022. 
 
You asked the Plan to pay for the ultrasound of abdominal aorta. You say that you feel this service should be 
covered because your benefits cover this service. The Plan denied your request. The Plan says this benefit has 
been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm. 
 We looked at the file and Medicare rules. The record shows that you received an ultrasound screening for 
abdominal aortic aneurysm on August 23, 2021, which was paid in full, and this benefit has been exhausted. 
Based on this information, we decided that Medicare rules for coverage of the ultrasound of abdominal aorta 
have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound of abdominal 
aorta (76706) provided on October 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on June 20, 
2022, to July 03, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this should be covered. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $250 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a $250 copayment per inpatient stay. Therefore, we decided 
that the Plan does not have to waive the copayment for inpatient hospital stay provided on June 20, 2022, to 
July 03, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on July 01, 2022, to July 22, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you shouldnt 
have to pay for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $188 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $188 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the Skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. You have been asked to pay a total of $1,880 ($188 x 10 days) copayment 
for your SNF stay. Therefore, we decided that the Plan does not have to waive the copayment for skilled 
nursing facility (SNF) care provided on July 01, 2022, to July 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 8, 2022, to June 
6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. 
 
  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from May 8, 2022, to June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 provided on July 13, 
2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 provided on July 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services provided on June 1, 2022, to June 29, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the billed services. You say that the records support the treatment for this 
enrollee. The Plan denied your request. The Plan says utilization of network providers and authorization for 
certain services is required. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the dialysis services provided on June 1, 2022, to June 29, 2022, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a breast implant (19342) and a revision of 
reconstructed breast (19380). 
 
You asked the Plan to pre-approve breast surgery. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested services are cosmetic in nature. 
 
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 breast surgery. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee underwent mastectomy in the distant past for benign disease. The enrollee 
underwent revision of implants in September 2020 and has breast asymmetry. The noted condition is not one 
for which coverage is available under the rules. The records provided do not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of a breast implant (19342) and a revision of reconstructed breast (19380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device identified with code 
E0652, and segmental pneumatic appliances identified with codes E0667 and E0656. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
identified with code E0652, and segmental pneumatic appliances identified with codes E0667 and E0656.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder arthroscopy with decompression, distal 
claviculectomy, and rotator cuff repair. 
 
You asked the Plan to pre-approve the surgical procedures. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the surgical procedures. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. 
 
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 surgical procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a shoulder arthroscopy with decompression, distal claviculectomy, and rotator 
cuff repair.