Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator provided on August 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
automatic external defibrillator. We found no exception that would require the Plan to pay for the automatic 
external defibrillator. The records provided for review do not show that the automatic external defibrillator was 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the automatic external 
defibrillator provided on August 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided from January 3, 2021, 
through January 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment cannot be made for the services 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided from January 3, 2021, through January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (85060) provided on January 15, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services are not covered because they 
were not billed with an appropriate place of service. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The records 
show that the services were not performed in the inpatient setting. 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 laboratory services (85060) provided on January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 8, 2021. 
 
You asked the Plan to pay for the laboratory 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 separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit and annual depression screening 
received on November 4, 2021. 
 
You asked the Plan to pay for the annual wellness visit and annual depression screening. You say that the new 
doctor was unaware there was an annual physical earlier in the year before you switched doctors. The Plan 
denied your request. The Plan says the services received exceed your benefit limit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an annual 
physical and annual depression screening once every 12 months.  
 
Based on review of the file, an annual physical and annual depression screening was provided less than 12 
months prior to the visit at issue in this case. You previously received these services on January 28, 2021. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit and annual depression 
screening received on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on January 18, 2022 to February 22, 
2022. 
 
You asked the Plan to pay for office visits. You say that you checked the enrollee's coverage prior to rendering 
services and the reports did not show/mention prior authorization was needed. 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 office visits provided on January 18, 2022 to 
February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on January 19, 
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 it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific 
(e.g. bilateral) code is available. 
 
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 00140 is not supported in the medical record. Specifically, two lateral diagnosis codes 
were used when a more specific bilateral code could have been used. 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 anesthesia services provided to the enrollee on January 19, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on February 1, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was taken to the nearest facility 
for treatment. The Plan denied your request. The Plan says that Medicare does not cover services that are not 
performed by a Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The enrollee received services at a freestanding emergency department. Per 
guidance from the Centers for Medicare and Medicaid Services (CMS), licensed independent freestanding 
emergency departments may participate in Medicare to help address the urgent need to increase hospital 
capacity to provide additional care during the public health emergency (PHE). The file shows that a waiver was 
provided to the facility prior to the date of service at issue. Per CMS guidance, this waiver will cease to be in 
effect when the Secretary determines there is no longer a public health emergency due to Covid-19. Based on 
this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for the emergency room services provided on February 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat lift mechanism, electric, any type (E0627) non-
covered item or service (A9270). 
 
You asked the Plan to pre-approve a lift chair and chair component. You say that you have problems with 
blood clots in your legs and not being able to move around. This would assist with your mobility issues. The 
Plan denied your request. The Plan says the available medical records do not support necessity of the device as 
defined by Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a Lift chair and chair component. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation of severe arthritis of the hip or a neuromuscular disease. There is no documentation in the office visit note that a seat lift 
is included in the treating practitioner's course of treatment. There is no documentation in the office visit note 
that a seat lift is likely to effect improvement in the enrollee's condition or arrest or retard deterioration in the 
enrollee's condition. There is no documentation that the enrollee is completely incapable of standing from a 
chair in the home and there is documentation that the enrollee has the ability to ambulate. 
 
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 Lift chair and chair component have not been met. Therefore, we decided that 
the Plan does not have to pre-approve seat lift mechanism, electric, any type (E0627) non-covered item or 
service (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on December 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider was out-of-network, but the 
facility was in-network. You say the enrollee had no choice in the medical professionals they saw while in the 
facility. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit.  
The records provided for review do not show that the domiciliary visit was urgent or emergent Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on December 29, 2021, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 7, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on February 7, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a home health visit provided by on January 5, 2022. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain the 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says that the rendering provider is an OON provider and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 
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. The Plan did not submit the proper Evidence of Coverage (EOC) for the date of 
service. In this case, the proper documentation was not received with the case file or when we requested the 
EOC on July 6, 2022, so we must find in your favor. Therefore, we decided that the Plan has to pay for a home 
health visit provided by on January 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 24, 2021. 
 
You asked the Plan to pay for the office visit. You say that you were never told there was or would be a 
consultation fee and you would not have gone for financial reasons. You say that you are not paying this charge 
due to never being told. The Plan denied your request. The Plan says only manual manipulation of the spine to 
correct subluxation is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on September 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF. 
 
You asked the Plan to pre-approve SNF. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing 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 SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from February 3, 2022, to February 
16, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. The Plan denied payment for the claim in this case due to the signature on the 
Plan of Care being on March 3, 2022, when the claim was submitted to the Plan originally on February 17, 
2022. However, the records show that the Plan of care was signed in February 2022. The burden is on the Plan 
to support why its denial is appropriate. Therefore, we decided that the Plan has to pay for the home health 
services provided from February 3, 2022, to February 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from October 11, 2021, to 
October 16, 2021, as billed with Diagnosis Related Group (DRG) 853. 
 
You asked the Plan to pay for inpatient care billed with DRG 853. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 853 is not appropriate as the diagnoses of sepsis, unspecified organism (A41.9) and acute renal failure with tubular 
necrosis (N17.0) are not supported in the medical record. The Plan argues that DRG 339 is more appropriate in 
this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 853. Our 
reviewer says that the diagnoses of sepsis, unspecified organism (A41.9) and acute renal failure with tubular 
necrosis (N17.0) are not supported in the records for this inpatient admission. Our physician reviewer found the 
enrollee presented to the emergency department on October 11, 2021, with abdominal pain in the right lower 
quadrant. The evaluation revealed stable vital signs, right lower quadrant pain to palpation, a white bloodcell 
count of 13T, creatinine 1.9, K+ 3.2 and abdominal computed tomography (CT) with acute appendicitis. He 
was evaluated by General Surgery and underwent laparoscopic appendectomy on October 12, 2021, which 
revealed a perforate retrocecal appendix. He was treated with IV fluids, IV antibiotics, insulin and IV 
analgesics. His condition stabilized and improved, and he was discharged home on October 16, 2021. The 
review has determined that the medical records do not support the billing of sepsis, unspecified organism 
(A41.9) and acute renal failure with tubular necrosis (N17.0). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 853 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from October 11, 2021, to October 16, 
2021, as billed with Diagnosis Related Group (DRG) 853.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on December 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that records support the performed procedure. 
The Plan denied your request. The Plan says an appropriate modifier was not appended. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232 was billed during a global surgery period for treatment of a fracture. The code at 
issue was not billed with a modifier to indicate the critical care service was unrelated to surgery. 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 the critical care services provided on December 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 23, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physical therapy services provided on December 23, 2021.