Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy and occupational therapy to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve outpatient physical therapy and occupational therapy. You say that the 
patient currently resides an Assisted Living Community and not a skilled nursing facility. You say the Assisted 
Living Community cannot directly provide therapy services as non-skilled staff do not have the knowledge and 
education in physiology and kinesiology required to develop and carry out a program designed to safely 
increase the functional task performance of a person with multiple medical considerations. You say your 
provider has an exclusive contract with the patient's Assisted Living Community to provide outpatient therapy 
services on-site at the community in California and this is very beneficial to the patient as he does not have to 
leave the facility to obtain therapy services. The Plan denied your request. The Plan says medically necessary 
care is available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient 
physical therapy and occupational therapy to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided August 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the equipment was prescribed by 
the doctor and was issued to the enrollee for use during their surgery. The Plan denied your request. The Plan 
says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
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 say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 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. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided August 
8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there 
are no issues for which LTACH may offer a therapeutic advantage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided July 18, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
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 say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 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. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided July 
18, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for a biopsy provided on July 6, 2022. We decided that 
the Plan does not have to waive the copayment for a biopsy provided on June 15, 2022.
 
You asked the Plan to waive the copayment for a biopsy provided on June 15, 2022, and July 6, 2022. You say 
that you did not have this done in an ambulatory area of the facility, it was done in the office. The Plan says 
that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for a biopsy provided on July 6, 2022.
 The Plan follows Medicare rules. 
The file shows that you have a medical indication for which Medicare will cover a biopsy. Therefore, we 
decided that the Plan has to waive the copayment for a biopsy provided on July 6, 2022.

We also decided that the Plan does not have to waive the copayment for a biopsy provided on June 15, 
2022. You will still be responsible for the $325 copayment. 
 
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 $325 
copayment for a biopsy provided on June 15, 2022. Therefore, we decided that the Plan does not have to waive 
the copayment for a biopsy provided on June 15, 2022.
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON routine transportation. You say that the enrollee needs assistance 
before and after procedure. The Plan denied your request. The Plan says medically necessary care is available 
in-network. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when provided by the Plans routine transportation vendor.  
We looked at your request, the records in the case file, and the rules. The requested provider in this case is not a 
network provider with the Plan. The Plan has network providers available who can provide the items/services 
at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. 
Based on this information, we decided that the Plans rules for coverage of routine transportation have not been 
met. Therefore, we decided that the Plan does not have to pre-approve routine transportation to be provided by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the physical therapy services provided on 
August 24, 2022. 
 
You asked the Plan to waive the deductible for therapy services. You say that you did not know the provider 
who performed the services was out-of-network. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to out-of-network therapy services. 
The Plan contract also say that enrollees must pay 45% coinsurance for out-of-network therapy services after 
the deductible has been met. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $750 deductible which applies to therapy services. This cost sharing is a contractual obligation that had not 
been met at the time therapy services was received on August 24, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for the physical therapy services provided on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 17, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not include documentation that 22 drug classes were performed. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing coded G0483 provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99251 billed for date of service September 
25, 2022. 
 
You asked the Plan to pay for procedure code 99251. You say that the services were medically necessary and 
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 99251 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99251 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99251 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99251 billed for date of service September 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) visit provided on July 4, 
2022, billed with code 99285. 
 
You asked the Plan to pay for the ED visit as billed. You say that it is felt that this was coded correctly. The 
Plan denied your request. The Plan says the billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 pose an immediate significant threat to life or physiologic function. 
 
 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 ED visit as billed. Our reviewer says that 
the documentation does not support the use of code 99285 for the services rendered. Our reviewer found the 
enrollee was evaluated in the ED and diagnosed with a left shoulder strain. The records show that the plan was 
to treat the enrollee with anti-inflammatory drugs and muscle relaxants and refer him to an orthopedist for 
follow-up. The records state that his cardiac heart score was 3 putting him in a low-risk category. The enrollee 
was told to follow-up with a cardiologist as well. He was deemed stable for discharge from the ED with plan 
for outpatient follow-up as noted. The review has determined that the documentation did not support procedure 
code 99285. There was no medical decision making of high complexity noted. 
 
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 ED visit as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) visit provided on July 4, 2022, billed with code 
99285.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the StimQ Peripheral Nerve Stimulator (PNS) System. 
 
You asked the Plan to pre-approve the StimQ PNS system. The Plan denied your request. The Plan says this 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 the StimQ PNS system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this device is considered experimental/ investigational. There is not enough data 
to support the use of a PNS for the pain of osteoarthritis of the knee. 
 
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 StimQ PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the StimQ Peripheral Nerve Stimulator (PNS) System.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from September 1, 2022, 
to September 29, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB 
code. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
September 1, 2022, to September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072, A4556, A4557, A4649, A9279, 
S1015, & S8301 billed for date of service September 6, 2022. 
 You asked the Plan to pay for procedure codes 99072, A4556, A4557, A4649, A9279, S1015, & S8301. You 
say that these services were medically necessary. The Plan denied your request. The Plan says the claim cannot 
be paid as billed. 
 
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 99072 has a Status Indicator of B on the Physician Fee Schedule. Procedure codes 
A4556, A4557 and A4649 have a status of P. Codes S1015, S8301, and A9279 have a status of I. These codes 
are not eligible for separate payment. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 99072, A4556, A4557, A4649, A9279, S1015, & S8301 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99072, A4556, A4557, A4649, A9279, S1015, 
& S8301 billed for date of service September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that to send your father to a non LTACH 
facility will essentially be sending him just to maintain not actually heal. The Plan denied your request. The 
Plan says the enrollee's medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has wounds drain and unable to take 
care of because of dementia and doesn't have anyone at home that can help drain it. The Plan denied your 
request. The Plan says the enrollee's records do not show the need for skilled nursing daily in an inpatient 
setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110-GP) provided on September 2, 
2022. 
 You asked the Plan to pay for therapeutic exercises. You say that this service was billed with an appropriate 
modifier as it was provided under a physical therapy plan of care. The Plan denied your request. The Plan says 
the modifier billed with this service is inconsistent with the reported revenue code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say only revenue 42x (physical therapy) lines may contain modifier GP.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapeutic exercises have not been met. Specifically, this service was billed with modifier GP and 
revenue code 0410. Lines which are not billed with a 42x revenue code cannot be billed with modifier GP. 
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110-GP) provided on 
September 2, 2022.