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

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service July 2, 2022. 
 
You asked the Plan to pay for procedure code 99283. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 
 
 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 99283 
is a column II code to column I code 99284. 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 99283 billed for date of service July 2, 2022.
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 enrollee still needs significant skilled nursing 
care to be able to return home. The Plan denied your request. The Plan says your request for approval of 
continued admission in a skilled nursing facility does not meet the requirements for approval. 
 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 have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does require skilled therapy 
services that require the specialized skill, knowledge, and judgment of a qualified therapist however, there is 
no documentation that further daily skilled services are required. Provided records do not document a 
significant improvement in the enrollees functional status despite daily therapy, and transition to part time 
therapy services now appears to be appropriate. The enrollee does not require daily skilled nursing or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Records support that services in the 
home or an assisted living facility with home health care or in a long-term care facility on a part time basis are 
appropriate in this case. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
provided on August 15, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say to please 
review these claims with the submitted documentation and reprocess. The Plan denied your request. The Plan 
says the documentation does not support medical necessity as there is no documentation that some means of 
transportation other than an ambulance could not be used without endangering the individual's health. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
emergency transport. Our reviewer says that the service is not medically necessary.  Our physician reviewer found the record indicates that the enrollee was ambulatory at the scene and transported 
in a semi-upright position. The record does not indicate that the enrollee's clinical condition is such that other 
methods of transport, such as stretcher van, are contraindicated or that the expertise, services and lifesaving and 
life-sustaining equipment that only a fully equipped ambulance can provide was required. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. 
 
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 ambulance service, basic life support, emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
emergency transport provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the office visit. We also decided that the Plan does 
not have to reduce the copayment for the EKG.  
 You asked the Plan to reduce the copayment for an office visit and electrocardiogram (EKG) provided on 
August 22, 2022. You say that the claim should have been coded at the high range instead of the specialist 
amount. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayment for the office visit.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). The Plan says that you must pay an $80.55 copayment for the 
office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $35 copayment for 
physician specialist services. Therefore, we decided that the Plan has to reduce the copayment for the office 
visit to $35.  
 
We also decided that the Plan does not have to reduce the copayment for the EKG. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). You have been asked to pay $14.45, which is less than the $95 
copayment for the EKG. This item/service falls within the diagnostic procedures and tests performed by a 
provider other than your PCP 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 reduce the copayment for the EKG. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine provided on September 
13, 2022. 
 
You asked the Plan to waive the copayment for nuclear medicine. You say that you want to appeal the amount 
being charged. 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 a $135 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $135 copayment for nuclear medicine. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and 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 nuclear medicine provided on September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiomyopathy, genomic sequence analysis 
panel, must include sequencing of at least 5 cardiomyopathy-related genes (81439) provided on August 25, 
2021. 
 
You asked the Plan to pay for the hereditary cardiomyopathy genomic sequence analysis panel. You say that 
the treating provider determined this testing to be medically necessary. The Plan denied your request. The Plan 
says this testing is non- covered as Medicare denies coverage for all cardiovascular risk assessment panels for 
patients with suspected or documented cardiovascular disease. 
 
The Plan follows Medicare rules. Medicare rules say that the Medicare policy denies coverage for all 
cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or 
documented cardiovascular disease. 
 
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 hereditary cardiomyopathy genomic 
sequence analysis panel. Our reviewer says that this testing does not meet criteria for coverage. Our physician 
reviewer found that the test is described as a genetic-based cardiovascular risk factor screening test in which 
multiple genes are assessed. It identifies the presence of pathogenic, or likely pathogenic, variants in genes 
known to be associated with increased cardiac risk. It is not a diagnostic test. There is no evidence to support 
its role in this patient's clinical management. In summary, the requested testing is not considered reasonable or 
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 hereditary cardiomyopathy genomic sequence analysis panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiomyopathy, genomic 
sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes (81439) provided 
on August 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to 
April 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to April 
12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency services provided on August 16, 
2022. 
 
You asked the Plan to waive the copayment for emergency services. You say that you were never at this 
hospital. 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 a $120 
copayment for emergency care.  
 
 
 You have been asked to pay $120 for emergency services.  This item/service falls within the emergency care 
benefit category. Records submitted indicate the service was provided. 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 emergency services provided on August 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 27, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the 
copayment. 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 a $35 
copayment for physician/practitioner services/specialist services.  
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist services 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 specialist office visit provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that supporting documents were provided. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular complete denture adjustment (D5411) provided 
on September 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a mandibular complete denture adjustment (D5411) provided on September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided 
August 26, 2022. 
 
You asked the Plan to pay for the orthoses. You say that the claim was prescribed by the enrollee's primary care 
physician n file and is currently covered under the coverage criteria for knee orthosis per the LCD. The Plan 
denied your request. The Plan says that the records do not support the service billed. 
 
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 pay for the orthoses. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee, with a diagnosis of osteoarthritis and bilateral knee instability who presented with 
increasing pain and difficulty walking. A knee orthosis was requested. The provided documentation showed 
evidence of knee instability via provocative testing, and with increasing pain it is reasonable to try a knee 
orthosis. The enrollee meets the LCD criteria for coverage. 
 
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 orthoses have been met. Therefore, we decided that the Plan has to pay for 
the knee orthosis (L1851) and suspension sleeve (L2397) provided August 26, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs these services to make a full 
recovery, The Plan denied your request. The Plan says the services the enrollee needs can be provided safely in 
another setting such as a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
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 there are no rehab nursing needs identified or documented. While the enrollee would 
benefit from physical therapy or occupational therapy, their rehab needs can be safely met in an alternate and 
low intensity setting such as in-home with 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 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from March 29, 2021, to March 
31, 2021. 
 
You asked the Plan to pay for the billed services. You say that per guidelines, there can be blank indicators. 
The Plan denied your request. The Plan says that the present on admission (POA) indicator is missing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The case file does not include the claim submitted for this case. There is no 
indication what diagnosis codes were assessed. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request.  Therefore, we decided that the 
Plan has to pay for the inpatient hospital services provided from March 29, 2021, to March 31, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your recommendation is for an intensive acute rehab 
program to assist the enrollee back to their prior functional status and be able to go home. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 12, 2022.