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

 
We decided that the Plan does not have to pay for the chest radiologic exam (x-ray) (71045), provided on 
September 14, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says there were no records submitted to show that two separate services were 
performed/supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the chest radiologic exam (x-ray) 
(71045), provided on September 14, 2021. have been met. There were no records submitted to show that two 
separate services were performed/supported. Therefore, we decided that the Plan does not have to pay for the 
chest radiologic exam (x-ray) (71045), provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel testing coded as 87798, 87653, 87651, 
87641, 87640, 87591, 87653, 87500, 87491, 87481 provided December 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you provide medically necessary services in 
good faith. In consideration for the services rendered, you are seeking reimbursement. The Plan denied your 
request. The Plan says the PCR testing is considered unproven and 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine PCR panel testing coded as 87798, 87653, 87651, 87641, 87640, 87591, 87653, 87500, 87491, 
87481 provided December 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on February 11, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 76700 and 93976. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 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 93976 
is a column II code to column I code 76700. 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 the abdominal ultrasound (76700) provided on February 11, 
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary as the enrollee's records show he is improving. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as an IRF.  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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 
23, 2021. 
 You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says an appropriate 
modifier was not billed. 
 
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 70450 is a column II code to column I code 70496. 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 the computed 
tomography (CT) scan provided on December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on December 22, 
2021. 
 
You asked the Plan to pay for the provided service. The Plan denied your request. The Plan says the 
documentation did not support the billed supply code. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation not indicate that the enrollee has had an in-person 
visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 
Based on this information, we decided that Medicare rules for coverage of the provided service have not been 
met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on 
December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit provided on March 9, 2022. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that this was a routine diabetic visit. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $40 
copayment for each podiatry visit.  
 
You have been asked to pay a $40 copayment for the podiatry visit. The podiatry visit falls within the Podiatry 
Services 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 a podiatry visit provided on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mattress overlay (E0371), provided on October 20, 2021. 
 
You asked the Plan to pay for the mattress overlay. You say that the item should be covered. The Plan denied 
your request. The Plan says the rental cap has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for these items of DME, A/B MACs (HHH) and 
DME MACs pay the fee schedule amounts on a monthly rental basis not to exceed a period of continuous use 
of 15 months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mattress overlay have not been met. Therefore, we decided that the Plan does not have to pay 
for the mattress overlay (E0371), provided on October 20, 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 LTACH is the safest discharge plan and 
allows for the highest level of recovery. 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 appears to be improving but is still unstable and should only require 
short-term acute care services that can be safely administered at the current facility until ready for discharge. 
There are no services at the LTACH which the enrollee requires that are not available at the current acute care 
facility. 
 
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 the orthosis provided on January 19, 2022. 
 
You asked the Plan to pay for the services provided. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the code denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 In this case, the CPT Code Manual definition of code L1690 is combination, bilateral, lumbo-sacral, hip, femur 
orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment. We 
find that CPT code L1690 was billed with diagnosis codes M16.11 and M16.12. There is a more appropriate 
code available to describe bilateral conditions. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the orthosis provided on January 19, 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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be currently more stable and improving and should only 
require short-term additional acute care services that can safely be performed at the current facility until more 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would 
not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and 
ground mileage (A0425) provided on October 16, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee required the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. The reviewer also found that the 
transportation could have been provided by other means (stretcher van, wheelchair van) without endangering the enrollees condition. Therefore, the reviewer found that the ambulance services were not medically 
reasonable or necessary on the date of service in this case. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428), and ground mileage (A0425) 
provided on October 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility admission provided by a 
participating provider. 
 
You asked the Plan to pre-approve a skilled nursing facility admission. You say that the longer you are in the 
hospital, the weaker you will become. The Plan denied your request. The Plan says THE enrollee does not have 
any daily skilled nursing needs, and needs can be met at a lower level of care.  
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 a skilled nursing facility admission. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no 
documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document that services in the assisted living facility with home health care or in a long-
term care facility on a part time basis are not appropriate in this case. 
 
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 skilled nursing facility admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a skilled nursing facility admission provided by a participating 
provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation (A0429, A0425) provided on 
October 7, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that the enrollee's coverage with their other 
insurance terminated in September of 2021, and therefore this Plan is the enrollee's primary insurer on the date 
of services. The Plan denied your request. The Plan says this claim cannot be processed without an explanation 
of benefits from the enrollee's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan directed the 
provider to send the bill to the primary insurer. The records held by the Centers for Medicare and Medicaid 
Services (CMS) show that the enrollees coverage with their primary insurer terminated on December 31, 2021, 
which means that coverage with the other Plan was in effect as the primary on the date in question. As the 
secondary insurer, the Plan cannot be held responsible for the ambulance transport until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation (A0429, A0425) provided on October 7, 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 IRF care is not medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that this individual will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The member continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement. 
However, the documentation does not support that he would meet criteria for admission to an acute inpatient 
rehabilitation facility. There is no indication that the member 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 his functional status. The member 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), and bone 
replacement graft for ridge preservation (D7953) provided on January 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not used your dental benefit for 2 
years. You say that you waited too long to address your dental issues. You say that you needed to have a tooth 
extracted. You also say that the services should be covered. The Plan denied your request. The Plan says 
guided tissue regeneration is not listed as a covered service. The Plan also says that bone replacement graft for 
ridge preservation is not listed as a covered service either. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the guided tissue regeneration and 
bone replacement graft for ridge preservation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266), and bone replacement 
graft for ridge preservation (D7953) provided on January 17, 2022.