Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from February 13, 
2022, to February 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the day of discharge, death, or a day on which a 
patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of 
admission.  
 
We looked at the file and Medicare rules. The file shows that the claim was incorrectly billed to include the enrollee's discharge day. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services rendered from February 13, 2022, to February 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided from August 22, 2022, to October 
10, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you never received a rejection letter. You 
say that you were informed over the phone of the rejection. The Plan denied your request. The Plan says the 
provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services 
performed by a provider that 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 the office 
visit provided from August 22, 2022, to October 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says PET scans of the brain to evaluate for possible or probable Alzheimer's 
Dementia and Dementia of Lewy Bodies are not covered. 
 
The Plan must follow Medicare rules. Medicare rules state that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months 
who meet certain diagnostic criteria. 
 
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 PET scan. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the provider suggested that 
the enrollee may have Alzheimer's or Dementia. According to the applicable NCD, PET/CT of the brain is 
covered for use in individuals who meet diagnostic criteria for both AD and FTD. There was no indication in 
the records provided that the member met diagnostic criteria for both AD and FTD (rather there was no 
mention of FTD). Therefore, a PET scan cannot be covered at this time. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroiliac joint injections (27096, 64493). 
 
You asked the Plan to pre-approve the sacroiliac joint injections. You say that these injections are medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 sacroiliac joint injections. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show the enrollee has chronic low back pain and the diagnosis of 
sacroiliitis. The records support that the injections are medically 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 sacroiliac joint injections have been met. Therefore, we decided that the 
Plan has to pre-approve sacroiliac joint injections (27096, 64493).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria and an LTACH level of care is necessary to achieve a safe and sustainable discharge. The Plan denied 
your request. The Plan says the enrollee does not meet all the requirements for an LTACH admission. 
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 17, 
2022, through June 15, 2022. 
 You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay was not medically necessary based on SNF criteria. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found limited records have been submitted for the date of service in question. These records 
do not show that the enrollee received or required skilled services. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 17, 2022, through June 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on August 30, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says that the code used to report these services is not 
supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
drugs from 19 drug classes were tested in this case. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on August 30, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 12001. You say that this is a separate procedure and should be 
paid. The Plan denied your request. The Plan says payment for code 12001 is bundled into payment for code 
11760. 
 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 12001 
is a column II code to column I code 11760. 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 12001 billed for date of service September 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you want to appeal this 
denial. The Plan denied your request. The Plan says prior authorization was not 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 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 the subsequent nursing facility care provided on February 14, 
2022, 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 office visit (99204) provided on October 20, 2022. 
 
You asked the Plan to pay for the office visit. You say that these services were performed at the request of the 
primary care physician at the facility. 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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the office visit have not been met. There is a more appropriate 
place of service code as well as more appropriate evaluation and management (E/M) service for this setting of 
service. Per Centers for Medicare & Medicaid Services (CMS) Evaluation and Management Services Guide, 
billing for an E/M service requires the selection of a Current Procedural Terminology (CPT) code that best 
represents the patient type, setting of service, and level of E/M service performed. CPT code 99204 for office 
or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. Place of 
service 11 was billed, however, the documentation received does not support the code billed as the visit was 
not performed in an office or other outpatient setting but rather in a mobile setting at the enrollee's home residence. Therefore, we decided that the Plan does not have to pay for the office visit (99204) provided on 
October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing of 1-7 classes (G0480) provided on 
September 7, 2021. 
 
You asked the Plan to pay for definitive drug testing of 1-7 classes. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for definitive drug testing of 1-7 classes was not filed until October 25, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for definitive drug testing of 1-7 classes (G0480) 
provided on September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wheelchair and accessories coded as 
K0006, E0971, E0961, E0951, E0978 and E2602 provided August 22, 2022. 
 
You asked the Plan to waive the copayment for the wheelchair and accessories. You say that you are appealing 
this cost share for items that you did not receive. 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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay $63.52 ($14.88 (K0006) + $12.78 (E0971) + $7.92 (E0961) + $5.06 (E0951) + 
$5.27 (E0978) + $17.61 (E2602)) 20% coinsurance for the wheelchair and accessories. This item/service falls within the Durable Medical Equipment (DME) and Related Supplies 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 the wheelchair and accessories coded as K0006, E0971, E0961, 
E0951, E0978 and E2602 provided August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the office POS code (11). 
The records do not support that the services were provided in an office setting. Therefore, we decided that the 
Plan does not have to pay for the services provided on October 12, 2022.
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the request for an IRF admission is denied as 
not medically necessary. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 9, 2022, 
to November 10, 2022 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says this admission has been correctly denied. 
 
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 the enrollee tolerated their post operative course well. 
 
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 November 9, 2022, to November 10, 
2022
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 4, 2022, to  
June 14, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says services from non-
participating providers are not covered under an HMO plan unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided from January 4, 2022, to June 14, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0429-EW) provided on July 15, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that these were ET3 ambulance services, and 
the "W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is 
an invalid destination modifier on ambulance claims. 
 
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 A0429-EW is supported in the medical record. Specifically, modifier W is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan 
has to pay for ambulance services (A0429-EW) provided on July 15, 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.