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

 
We decided that the Plan does not have to pay for BLS non-emergency ambulance (A0428) and ground 
mileage (A0425) provided September 18, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the records should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the members terminal condition until the first 
day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on 09/22/2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for BLS non-emergency 
ambulance (A0428) and ground mileage (A0425) provided September 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 19, 2021. 
 You asked the Plan to pay for the services provided. You say that the services were deemed medically 
necessary. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnosis 
listed. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. The file shows that fluorescence in situ hybridization (eg, FISH) 
testing was provided. This testing is used to identify suspected diseases, such as bladder cancer. In this case, 
there are no medical records from the treating physician to determine how the results of the testing would be 
used in the medical management of the enrollee. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on June 15, 2021. 
 
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 is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the chest x-ray rendered on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on 
September 20, 2021.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81291) provided October 20, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for dates of service after July 1, 2011, 
A/B MACS shall automatically deny claim lines submitted with the GZ modifier. 
 
We looked at the file and Medicare rules. The claim was billed with the GZ modifier. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81291) provided October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy (surgery to remove extra fat and skin 
from the waistline) (CPT code 15830). 
 
You asked the Plan to pre-approve the service. You say that you keep getting sores and it is very painful to 
have extra skin. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 service have not been met. Medicare will not cover skin 
removal surgery if is less than 18 months from your weight loss surgery. Therefore, we decided that the Plan 
does not have to pre-approve panniculectomy (surgery to remove extra fat and skin from the waistline) (CPT 
code 15830).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on December 2, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services can be received in-network. 
 
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 outpatient surgery services provided on December 
2, 2021 by an out-of-network (OON) provider.
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 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. The enrollee is ambulating more than one 
hundred (100) feet and tending to activities of daily living (ADLs) with minimal supervision. 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 SNF care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavior health services provided on January 7, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the behavior health services. You say that the service provided does not need an 
authorization or a referral and you would like to resubmit the claim. 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 the behavior health services provided on January 
7, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 15, 2021 to 
August 18, 2021. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes (Q5001, Q5002, and Q5009). 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required G 
and Q codes. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the home health services rendered from August 
15, 2021 to August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on January 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
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 payment for CPT code 85606 is not supported in the medical record. Specifically, the services 
were billed with an outpatient hospital place of service. Code 85060 is assigned a PC/TC indicator of 8. This 
means that no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. 
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 the services (85060) provided on January 3, 2022.
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 November 1, 2020, to November 18, 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 there were no daily skilled needs requiring care in the skilled nursing facility (SNF). 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there are no 
identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee 
does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 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 November 1, 2020, to 
November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and podiatry service provided on August 9, 
2021. 
 
You asked the Plan to pay for an office visit and podiatry service. You say that there was not sufficient time to 
obtain an authorization. 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 an office visit and podiatry service provided on 
August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the sensor is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet prior authorization criteria. 
 
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 and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor (K0553).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) 
provided on November 26, 2021. 
 
You asked the Plan to pay for ambulance response without transport. You say that you called your spouse to 
pick you up when you started to feel unwell at a health club. Another member called an ambulance for you, 
which you did not request or need, and you went home with your spouse shortly after the ambulance arrived. 
The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no 
transportation is provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport (A0998) provided on November 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on December 10, 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 that this service was billed without anesthesia minutes. 
 
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 01996 is "Daily hospital management of epidural or subarachnoid continuous drug administration." 
 
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 supported by the medical records. Our reviewer found that the anesthesiologist billed CPT code 
01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) on 
12/10/2021.  The continuous epidural infusion included Bupivacaine 0.2% plus Fentanyl 2mcg. The post-
operative pain visit/anesthesia note on 12/10/2021 (at 09:25) documents that CPT code 01996 was 
appropriately billed.  This CPT code is billed with base units only and not by anesthesia time/minutes. No 
anesthesia minutes need to be documented, as this daily hospital management is billed with the assigned base 
units only. The records support that CPT 01996 was billed correctly. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
anesthesia services provided to the enrollee on December 10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transfer bench for tub (E0247) and applicable sales tax 
provided on November 16, 2021. 
 
You asked the Plan to pay for a transfer bench for tub. You say that the item at issue is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the item at issue is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that bathtub lifts are not covered because they are not 
primarily medical in nature.  
 
While a transfer bench for tub may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pay for a transfer bench for tub (E0247) and 
applicable sales tax provided on November 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 16 to 
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 16 to 
December 23, 2021.