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

 
We decided that the Plan does not have to reimburse you for the nursing home care provided from May 14, 
2021, to August 22, 2021. 
 
You asked the Plan to reimburse you for the nursing home care. You say that you sent the claim to Medicare. 
You say that they advised they do not pay for nursing home care. You also say that the services the enrollee 
received during their stay was more than custodial. The Plan denied your request. The Plan says nursing home 
care is not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nursing home care have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for 
the nursing home care provided from May 14, 2021, to August 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography (procedure code 75710) provided to the enrollee 
on January 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is considered inclusive to CPT 37225. 
 
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 75710 is "Angiography, extremity, unilateral, 
radiological supervision and interpretation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that when using CPT 75710 with 
modifier 59, there are requirements met to be able to code this separately. This code is not additionally reported 
for diagnostic lower extremity angiography when performed through the same access site as the therapy 
performed in the same session. However, catheterization for the diagnostic lower extremity angiogram may be reported separately if a different arterial puncture site is necessary. Per the description of the procedure, there 
was no different arterial puncture site when they performed the angiography on the popliteal. Therefore, the use 
of modifier -59 was not appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography (procedure code 75710) provided to the enrollee on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 22, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting a reconsideration for services 
rendered. The Plan denied your request. The Plan says the out-of-network services were 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 an office visit provided on December 22, 2021, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99053) provided on December 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services 
(99053) provided on December 9, 2021.
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 the enrollee qualifies to be admitted to 
the LTACH, and care cannot be safely provided at a lesser level of care. The Plan denied your request. The 
Plan says the denial of authorization for LTACH care is correct. 
 
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 is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires which are not available at the current healthcare 
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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PMP22 genetic testing (codes 81324 and 81325) provided on 
November 2, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that test codes 81324 and 81325 are unlikely to 
impact therapeutic decision-making and will be automatically denied.  
 
We looked at the file and Medicare rules. These tests are not covered by Medicare. Based on this information, 
we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for PMP22 genetic testing (codes 81324 and 81325) provided on November 2, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted case management services coded T1017 
provided on February 16, 2022. 
 
You asked the Plan to pay for the targeted case management services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code T1017 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code T1017 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the targeted case management services have not been met. Therefore, we decided that the Plan 
does not have to pay for the targeted case management services coded T1017 provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81295, 81298) provided on January 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81295 
and 81298 are column II codes to column I code 81432 with a modifier indicator of 0. The column II codes are 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (81295, 81298) provided on January 31, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient mental health services provided from January 25, 2022, to 
February 10, 2022. 
 
You asked the Plan to pay for inpatient mental health care. You say that the enrollee was a danger to herself 
and others, and these services were medically necessary. The Plan denied your request. The Plan says that the 
diagnosis code/service code are inconsistent with each other. A corrected claim with proper codes used for the 
inpatient services must be submitted. 
 
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. Specifically, the Plan has not specified which codes are inconsistent with each 
other, and the Plan has not provided any citation to support their argument. The Plans denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pay for inpatient mental health services 
provided from January 25, 2022, to February 10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the hips (73522) provided on February 15, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the X-ray exam of the hips. You say that the provided care was medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained for the services 
rendered by an OON provider. 
 
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 X-ray exam of the hips (73522) provided on 
February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral to a vascular surgeon. 
 
You asked the Plan to pre-approve the referral. You say that there is no vascular surgeon in-network. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 vascular 
surgeon 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. Therefore, we decided that the Plan does not 
have to pre-approve an out-of-network referral to a vascular surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 28, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 28, 
2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says this request does not meet the coverage criteria. 
 
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 in this case, the complexity of your nursing, medical and rehabilitation needs do 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement; however, the documentation doesnt support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. You can 
receive further services at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
22, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldn't have to pay 
this every time you go to the doctor. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $25 
copayment for each Medicare covered specialist visit.  
 
You have been asked to pay $25 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist office visit provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection of lower or sacral spine facet joint using imaging 
guidance, single level (CPT code 64493). 
 
You asked the Plan to pre-approve the injection. You say that you are in extreme chronic pain, and nothing is 
working. The Plan denied your request. The Plan says that there has been at least three (3) months of moderate 
to severe neck or back pain that limits daily activity. The Plan states a trial of treatment that has not helped, and 
the procedure will be done at a level of the spine where there has not been a prior fusion surgery. The Plan 
states there are not any of the following: an infection; tumor; fracture; and/or major deformity. 
 
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 injection. Our physician reviewer 
found you have ongoing pain despite reprogramming attempts. A trial of diagnostic L5, ala blocks meet LCD 
criteria and is medically 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve injection of lower or sacral spine facet joint using imaging guidance, single level (CPT code 64493).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig. 
 
You asked the Plan to pay for wig. You say that it was medically necessary for you to purchase this wig. The 
Plan denied your request. The Plan says this item is not covered by Medicare. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided 
to the enrollee on November 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service was inappropriate for this procedure. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does not support the use of procedure code 99153 in this case, as there is no clear description of the additional 15 
minutes used for the sedation services provided by the primary surgeon on the case. The documentation must 
clearly state how the provider did the additional workup intraservice, and that was not apparent in this 
documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on November 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
29, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldn't have to pay 
this every time you see the doctor. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $25 
copayment for each Medicare covered specialist visit.  
 
You have been asked to pay $25 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist office visit provided on March 29, 2022.