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

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 15, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71046. 
 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 71046. 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 January 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210 x 2), deep sedation (D9222, 
D9223), and therapeutic parenteral drug (D9630). 
 
You asked the Plan to pre-approve the dental services. You say that your tooth is broken below the gum line. 
You say that you are concerned about infections and getting an abscess. You also say that your dentist 
recommended an oral surgeon complete these services. The Plan denied your request. The Plan says the 
requested services are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested extractions, deep 
sedation, and therapeutic parenteral drug are not among those covered under this benefit. Additionally, the 
services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The record shows that the extractions are being requested as a result of dental caries and 
therefore are not covered under Medicare. Additionally, since the initial procedure is not covered, any 
associated services are not covered either. Therefore, we decided that the Plan does not have to pre-approve 
surgical extractions (D7210 x 2), deep sedation (D9222, D9223), and therapeutic parenteral drug (D9630).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee's physical function is at or near 
their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehabilitation services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jazzy Air 2 power wheelchair (E1399). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee has both legs amputated from 
the knees down and has chronic recurrent sacral ulcers, malnutrition, liver cirrhosis, and severe advanced 
neuropathy. The current wheelchair does not have the right support needed. You also say the enrollee requires 
this chair for normal day to day activities outside of the home. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for this wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
are met. 
 
The file shows that the enrollee currently has a wheelchair. The file also shows that the enrollee is requesting 
this new wheelchair primarily for use outside of the home. Medicare rules says that if you request a wheelchair 
for use outside of the home, it will not be covered. This means that Medicare rules for coverage of a PMD have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Jazzy Air 2 power wheelchair 
(E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the Plan's decision. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and there is no 
referring provider involved in these services. The Plan also says that they did not authorize any services for this 
provider. 
 
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 an office visit provided on May 25, 2021, by an 
out-of-network (OON) provider.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for knee replacement and 
developed post-operative sepsis. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Drainage of retroperitoneal abscess (49060) provided on 
September 28, 2021. 
 
You asked the Plan to pay for code 49060. You say that the medical records support the billing of code 49060 
provided on September 28, 2021. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 49060 provided on September 28, 2021. 
 
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 49060 is Drainage of retroperitoneal abscess, open. 
 
 
 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 code 49060. Our reviewer says that the medical records do 
not support the billing of code 49060 provided on September 28, 2021. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria.  The operative report describes abdominal washout.  In this 
case, the operative report does not document an open drainage of abscess, and therefore cannot be verified.  
There is a more appropriate code that should be reported to support documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 49060 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Drainage of retroperitoneal abscess (49060) provided on September 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services (G0402, G0463 and 71046) 
provided on September 13, 2021. 
 You asked the Plan to pay for outpatient hospital services. You say that these services were billed correctly and 
are supported in the record. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that hospitals subject to OPPS must report Condition 
Code G0 on FLs 24-30 (or the corresponding electronic location) when multiple medical visits occurred on the 
same day in the same revenue center but the visits were distinct and constituted independent visits.  
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, CPT codes G0402 and G0463 were billed with 
the same revenue code on the same date of service. This claim was not billed with the required G0 condition 
code to indicate that these visits were distinct and constituted independent visits. Therefore, we decided that the 
Plan does not have to pay for the outpatient hospital services (G0402, G0463 and 71046) provided on 
September 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 15, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain the 
authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on November 15, 
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 11, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider ordered the laboratory 
test, and that the specialized test is not available with any other provider. The Plan denied your request. The 
Plan says the rendering and referring providers are both OON providers and there was no approved 
authorization. Also, the service provided was not urgent or emergent. 
 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 the laboratory services provided on November 11, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure (49999) provided on July 20, 2021. 
 
You asked the Plan to pay for the unlisted procedure (49999). You say that the surgery was medically 
necessary to treat the patient's malignant neoplasm of overlapping sites of pancreas. You say that the 
documentation supports justification for payment of CPT code 49999. The Plan denied your request. The Plan 
says procedure code 49999 is not supported by the medical records submitted. 
 
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 is unlisted procedure, abdomen, peritoneum and 
omentum. 
 
  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 unlisted procedure (49999). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes a Falciform ligament flap. There is no CPT code for this procedure, and no definitive 
guidelines were found to support reporting this procedure. 
 
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 unlisted procedure (49999) have not been met. Therefore, we decided that 
the Plan does not have to pay for the unlisted procedure (49999) provided on July 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation beyond the Plan's 50-mile trip 
limit. 
 
You asked the Plan to pre-approve routine transportation. You say that you need transportation to your 
appointment. The Plan denied your request. The Plan says this trip is not covered because it exceeds the 50-
mile limit. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when within a 50-mile limit.  
 
We looked at your request, the records in the case file, and the rules. In this case the trip being requested is over 
50 miles. We find no exception that would require the Plan to cover the requested trip. Based on this 
information, we decided that the Plans rules for coverage of routine transportation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve routine transportation beyond the Plan's 50-
mile trip limit.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost for the office visit. We decided that the Plan does not have to 
waive the cost for the ultrasound.  
  You asked the Plan to waive the copayment for the office visit and ultrasound. You say that this was a simple 
non-imaging ultrasound that was necessary. You say that this was not available at your primary care physician's 
office and the $75 deductible should be waived. The Plan says that the $75 copayment applied correctly. 
 
We decided that the Plan has to reduce the cost for the office visit.  
 
The Plan says you must pay a $75 copayment for the office visit and ultrasound. The office visit is not 
considered a diagnostic test or procedure. The office visit would apply a $25 copayment for in-network, 
physician specialist services. Therefore, we decided that the Plan has to reduce the cost for the office visit from 
$65.13 to $25.  
 
We also decided that the Plan does not have to waive the cost for the ultrasound. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic procedures and tests performed by a network provider other than your primary care 
physician. You have been asked to pay $9.87, which is less than the standard $75 copayment for the 
ultrasound. Therefore, we decided that the Plan does not have to waive the cost for the ultrasound. 
 
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 service is necessary for the enrollee at this time 
to regain maximum function. The Plan denied your request. The Plan says the stay is not medically necessary 
based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of a small bowel obstruction. Medical problems are stable.  There are no complex nursing or rehabilitation needs. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0480) 
provided on February 23, 2021. 
 
You asked the Plan to pay for the laboratory 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 laboratory services have not been met. Code(s) G0480 and 
80307, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (CPT code(s): 80307 and G0480) provided on February 23, 2021.