Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 14, 
2022, through February 15, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services at issue were medically 
necessary. The Plan denied your request. The Plan says the services were not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the documented presentation and initial response to treatment, it was not 
expected that the enrollee would require hospital services that would likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 14, 2022, through 
February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 23, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you don't think that you should 
have been charged this fee. 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 $250 
copayment for ambulatory surgical center visit.  
 
You have been asked to pay $250 copayment for outpatient surgery. This item/service falls within the 
ambulatory surgical center visit 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 
outpatient surgery provided on May 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 20, 
2022. 
 You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 31500. 
 
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 71045 is a column II code to column I code 31500. 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 71045 
billed for date of service February 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SoClean continuous positive airway pressure (CPAP) 
machine adapter (A9270). 
 
You asked the Plan to pre-approve a CPAP machine adapter. You say that the requested adapter is a necessity 
for sanitary reasons, to keep the mask clean. Your primary care provider requested the adapter, and you are 
asking that the plan reconsider this denial. The Plan denied your request. The Plan says the requested adapter is 
considered a hygienic supply, not primarily medical in nature, and therefore not covered by Medicare or the 
plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a SoClean continuous positive airway pressure (CPAP) 
machine adapter (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair (PWC) and accessories (CPT code K0856).

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the enrollee does not have a medical need for a group 3 power wheelchair with the requested power option(s)/feature(s).

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 DME. Our physician reviewer found the request for a Group 3 power wheelchair with tilt is not medically necessary and exceeds the enrollee's medical needs.  The documentation does not reveal that the enrollee is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. Therefore, the request for a Group 3 power wheelchair with tilt exceeds the patient's medical needs and is not medically necessary per Medicare Guidelines.

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair (PWC) and accessories (CPT code K0856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services (CPT code 99153) provided on May 27, 
2022. 
 
You asked the Plan to pay for the sedation services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the sedation services have not been met. The provider did not bill 
as required by Medicare coding regulations. CPT code 99153 has a Professional Component (PC)/Technical 
Component (TC) indicator of 3 per the 2022 National Physician Fee Schedule Relative Value File April 
Release. CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital 
outpatient department. Therefore, we decided that the Plan does not have to pay for the sedation services (CPT 
code 99153) provided on May 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for date of service June 18, 
2022, to June 22, 2022. 
 
You asked the Plan to pay for procedure code S9502. 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 S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9502 billed for date of service June 18, 2022, to June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 25, 2021. 
 
You asked the Plan to pay for the testing services. You say that a 26 modifier is not required. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that the enrollee was an inpatient at the time the services were provided. We looked at the file 
and the rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for 
services furnished to a beneficiary. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers.  This service was provided via arrangement of the facility. Payment for this service would have been included 
under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing services provided on June 25, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implantation of a sacral-nerve neurostimulator (64581, 64590). 
 
You asked the Plan to pre-approve implantation of a sacral-nerve neurostimulator. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover sacral nerve 
modulation/stimulation for fecal incontinence when all of the criteria listed in the Medicare rules section of this 
letter are met. 
 
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 implantation of a sacral-nerve 
neurostimulator. Our reviewer says that the requested services are considered medically reasonable and 
necessary in this case. Our physician reviewer found that the records show the enrollee has failed conservative 
management and has had a successful neuromodulation trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a sacral-nerve neurostimulator have been met. Therefore, we 
decided that the Plan has to pre-approve implantation of a sacral-nerve neurostimulator (64581, 64590).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of benign tumor or cyst of maxilla (21026), 
removal of impacted tooth (D7240), surgical extraction (D7210), and moderate sedation services (99152 and 
99153) provided on September 14, 2021.  
You asked the Plan to pay for the excision of benign tumor or cyst of maxilla, removal of impacted tooth, 
surgical extraction, and moderate sedation services. You say that these services should be covered under your 
medical insurance, as this was surgery to remove a cyst/tumor, facial bone, molar, and impacted wisdom tooth. 
You also say that these services were not routine dental work and for the possibility of cancer. The Plan denied 
your request. The Plan says outpatient hospital, anesthesia, and professional services for routine dental care are 
not covered. 
 
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 excision of benign tumor or cyst of 
maxilla, removal of impacted tooth, surgical extraction, and moderate sedation services have been met. 
Medical records were not provided for this case. We asked for these documents, but they were not provided to 
us. While these services may be covered under your medical insurance, this cannot be determined without 
medical records. The record also shows that on September 14, 2021, you signed a Notice of Medicare Non-
Coverage acknowledging that the services would not be covered. Therefore, we decided that the Plan does not 
have to pay for the excision of benign tumor or cyst of maxilla (21026), removal of impacted tooth (D7240), 
surgical extraction (D7210), and moderate sedation services (99152 and 99153) provided on September 14, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation service provided 
on June 10, 2022. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation service. You say that you were 
informed that you were eligible for 20 visits with no cost share to you. 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 $60 
copayment for Medicare-covered physical therapy visit.  
 
You have been asked to pay $60 copayment for outpatient rehabilitation service. This item/service falls within 
the Medicare-covered physical therapy visit 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 outpatient rehabilitation service provided on June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).

You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L4, L5, and S1, in this case, is not medically reasonable or 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99309 provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for code 99309. You say that these medically necessary services were provided in 
good faith. The Plan denied your request. The Plan says 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 in this case is not a network provider with the Plan. 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 code 99309 provided on February 15, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 4, 2022.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the appropriate claim information must be submitted. 

We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 procedure code 70450 billed for date of service July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for canalith repositioning and a therapeutic procedure provided 
on March 3, 2022 and March 22, 2022, by an OON provider. 
 
You asked the Plan to pay for canalith repositioning and a therapeutic procedure. 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 canalith repositioning and a therapeutic procedure 
provided on March 3, 2022 and March 22, 2022, by an OON provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (G0482) provided on September 1, 2021.

You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported as billed. The Plan denied your request. The Plan says that this claim was submitted with an incorrect place of service code.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. The rules also 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 argues that this claim was submitted with an incorrect POS code (which they state was code 99) but the medical documentation indicates that the specimen was obtained in an office setting. However, the claim provided shows that POS code 11 (office) was reported. As the records support that the sample was collected in an office setting and the office POS code was reported, the Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for laboratory services (G0482) provided on September 1, 2021. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from the highest level of rehabilitation to regain their maximum function. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for approval.

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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met 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 IRF admission and services.