Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on September 2, 2021. 
  You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate when services are not available from preferred providers in 
the service area. You say that the in-network benefits should be honored, and the claim processed for payment. 
The Plan denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist 
billed as services incident to a physician/non-physician practitioners service must meet all incident 
requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, OT services cannot be paid incident to this provider's professional services. Therefore, 
we decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 4, 2021. 
 
You asked the Plan to pay for the testing services. You say that the drug screen provides valuable information 
for physician to use. The Plan denied your request. The Plan says the service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that CPT code G0483 is not supported in the medical record. Specifically, medical records were not 
provided to show the billed code meets coverage criteria. The Plan made several attempts to obtain additional 
information, which was not received. 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 drug testing services 
provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97813) acupuncture, each 
additional 15 minutes (97814) provided August 4, 2021 
 
You asked the Plan to pay for the acupuncture services. You say that you request that after reviewing the 
attached medical records that all services be reprocessed and paid. The Plan denied your request. The Plan says 
the services was rendered by a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the health Plan contract says that the service must be 
provided by a legally qualified physician practicing within the scope of their license. The services was provided 
by a licensed acupuncturist, not a physician. Therefore, we decided that the Plan does not have to pay for 
acupuncture, initial 15 minutes (97813) acupuncture, each additional 15 minutes (97814) provided August 4, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 26, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim billed a place of service as 81, an independent laboratory. The 
records do not show that the specimen was obtained at the independent laboratory. 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 drug testing services provided on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient psychiatric admission provided from
January 17, 2021, through January 27, 2021.
You asked the Plan to pay for the inpatient psychiatric admission. The Plan denied your request. The Plan says
the inpatient psychiatric admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric admission. Our
reviewer says that the inpatient psychiatric admission was not medically necessary and reasonable. Our
physician reviewer found that based upon review the records provided it was not expected this enrollee would
improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness
to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any
acute threats of safety. The enrollee was cooperative and compliant with medication. It did not appear
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather
than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts,
auditory or visual hallucinations or abnormal behaviors. The health Plan's denial of continued inpatient
psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond
the dates in question as noted above as he was not a danger to himself or others and did not have any delusions,
auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in
question. It did not appear that the services for the dates in question were reasonably expected or medically
necessary to improve the enrollee's condition or for the purpose of diagnosis. It appears that the services were
supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question and could
have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation,
auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative
and compliant while not showing any acute threats to safety.
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 inpatient psychiatric admission have not been met. Therefore, we decided
that the Plan does not have to pay for an inpatient psychiatric admission provided from January 17, 2021,
through January 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 2 to 
September 29, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that you understood the Plan to pay for out-of-
network services. The Plan denied your request. The Plan says rules for payment have not been met because 
the provider at issue has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services (90834) provided on June 2 to September 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 23, 2021, to 
July 18, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says no payment is due to the non-contracted 
provider as the RAP was submitted outside of the Centers for Medicare & Medicaid Services timeframe. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, June 23, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from June 23, 2021, to July 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 26, 2020, to August 31, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
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 the records do not support a diagnosis 
of dysphagia as a speech language pathology comorbidity. The nutritional assessment completed on 8/31/20 
documents no swallowing problems. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from August 26, 2020, to 
August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553), provided on July 4, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the date of service does not match the shipment or delivery date. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The date of service does not match the shipment or 
delivery date. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor 
(CGM) (K0554) and supplies (K0553), provided on July 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 6, 
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 provider did not bill as required 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 63042 
is a column II code to column I code 63047. 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 surgical services provided to the enrollee on October 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 14, 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 this service should not be unbundled. 
 
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 77065 is a column II code to column I code 77066. 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 imaging services provided to the enrollee on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313),
attendant control (E2331) and electronic connection (E2311).
You asked the Plan to pre-approve the power wheelchair accessories. You say that the items are medically
necessary. The Plan denied your request. The Plan says the items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition
to a beneficiary-operated drive control system, it will be denied as non-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 power wheelchair accessories.
Our reviewer says that the items are not medically necessary. Our physician reviewer found the enrollee is
independent with feeding thus indicating he has adequate upper extremity strength and function to operate the
wheelchair's power options with their own switches.
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 power wheelchair accessories have not been met. Therefore, we decided that
the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), attendant control
(E2331) and electronic connection (E2311).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 16, 2021, to 
June 4, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the initial Request for Anticipated 
Payments (RAP) claim was not received within 5 calendar days from the start of care. The Plan also says that 
the RAP claim was submitted on September 27, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, May 16, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from May 16, 2021, to June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating, per lens (V2750) provided on  
May 10, 2021. 
 
You asked the Plan to pay for the anti-reflective coating, per lens. The Plan denied your request. The Plan says 
this service is not covered by the Plan. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that anti-reflective coating is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for anti-reflective coating, per lens (V2750) provided 
on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cerumen removal provided to the enrollee on June 29, 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 69209 is "Removal impacted cerumen using 
irrigation/lavage, unilateral." 
 
We find that CPT code 69209 is not supported in the medical record. Specifically, a place of service of on 
campus outpatient hospital would not be appropriate, as the PC/TC indicator is 5.. 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 cerumen removal provided to the enrollee on June 
29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genomic sequence panel provided on August 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the testing identifies potential targeted 
therapy options. The Plan denied your request. The Plan says the screening testing is not covered. 
 
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. The rules say that genomic profile test, billed with code 81455 is 
unlikely to impact therapeutic decision making. 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 genomic sequence panel provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) and battery charger (E1357) 
purchased on August 9, 2021. 
 
You asked the Plan to pay for an oxygen concentrator and battery charger. You say that the items at issue were 
not available for rental and had to be purchased outright. The Plan denied your request. The Plan says rules for 
payment for oxygen equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator 
and battery charger have not been met. Therefore, we decided that the Plan does not have to pay for an oxygen 
concentrator (E1390) and battery charger (E1357) purchased on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve imaging services. You say that it is necessary for these services to be 
performed by an OON provider. The Plan denied your request. The Plan says there are in-network providers 
that can provide the necessary imaging services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
imaging services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor. 
 
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
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 indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve lumbar RFA. You say that these services are medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that initial RFA services are covered when the 
enrollee has had at least two medically reasonable and necessary diagnostic MBBs.  
 
We looked at the file and Medicare rules. In this case, the documentation confirms that only one MBB has been 
performed at this time. Based on this information, we decided that Medicare rules for coverage of lumbar RFA 
have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar radiofrequency 
ablation (RFA) services.