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

 
We decided that the Plan does not have to waive the copayment for the echocardiography, transthoracic, real-
time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography (93306) provided July 21, 2021. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that you were not notified by 
the provider's office that there would be a copayment. The Plan denied your request. The Plan says the 
copayment was applied 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 $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility.  
You have been asked to pay a $110 copayment for the echocardiography. The echocardiography 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 the echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with 
color flow Doppler echocardiography (93306) provided July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided October 21, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you needed a new dentist who 
required new x-rays because your previous x-rays were unreadable. The Plan denied your request. The Plan 
says you have exceeded the frequency limit for this service. 
 
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 Plan covers the 
comprehensive oral exam once every 3 years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral 
exam was previously covered on January 7, 2021.  Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral 
exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation - new or established patient (D0150) provided October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 1, 
2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that the reports support the 
service billed. You say that you are eligible for separate reimbursement from the facility and the claim should 
be sent back for reprocessing. The Plan denied your request. The Plan says CPT code 99152 is supported on 
appeal. The Plan also says that CPT code 99153 remains denied as the provider did not bill as required by 
Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that carriers may not pay for 
the technical component (TC) of radiology services furnished to hospital patients. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage of the moderate sedation services have not been met. Specifically, CPT code 
99153 is a TC only code and the claim indicates that this service was rendered in a facility setting. Payment for 
CPT code 99153 is made to the facility and is the responsibility of the facility to pay any physician or vendor. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided 
on June 1, 2021.
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 is stable enough for discharge to an IRF. 
You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says 
the guidelines for coverage have not been met. The Plan says that the enrollee's needs can be met in an alternate 
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. Our 
physician reviewer found the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. At the current functional mobility level, the 
enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack 
of medical complexity, and lack of acute rehabilitation nursing needs and high functional mobility level. While 
the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can 
be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF.) 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a new patient office eye exam 
provided on August 31, 2021. 
 
You asked the Plan to pay for the physician's services. You say that these services were for your yearly diabetic 
exam, and you were told by the provider's office that he participates with your insurance. The Plan denied your 
request. The Plan says the services do not qualify as urgent and/or emergent services and the Plan was not 
contacted for prior approval. 
 
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 physician's services for a new patient office eye exam provided 
on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care. 
 
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  
 
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 admission to a long term acute care hospital (LTACH).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laminectomy, facetectomy and foraminotomy (63047-59, 
63048x2) provided on October 11, 2021. 
 
You asked the Plan to pay for a laminectomy, facetectomy and foraminotomy. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the provided 
documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  The rules also state that providers may bill services with a -59 modifier if the service billed with the modifier 
indicates a distinct procedural service. 
 
In this case, the CPT Code Manual definition of code 63047 is "Laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; lumbar" and the definition of code 63048 is "Laminectomy, 
facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or 
nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, 
cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)." 
 
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 a laminectomy, facetectomy and foraminotomy. Our 
reviewer says that the codes at issue do not meet criteria for payment. Our reviewer found that the provider 
reported 2 units for the services coded 63048. The provided documentation does not support 2 units, as the 
operative report documents L4-L5, S1 for services performed on. Furthermore, CPT 63048 would be inclusive 
to CPT 22633, as documentation does not support additional work required to complete a decompression at a 
single spinal level. CPT 63047 would also be inclusive to CPT code 22633, as there is no documentation of 
additional work required to complete a decompression at a single spinal level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a laminectomy, facetectomy and foraminotomy have not been met. Therefore, 
we decided that the Plan does not have to pay for a laminectomy, facetectomy and foraminotomy (63047-59, 
63048x2) provided on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left cryo ROM knee orthosis (L1833). 
 
 
You asked the Plan to pre-approve a left cryo ROM knee orthosis. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says the use of active or passive cooling devices has not 
been proven to provide significant differences in pain, swelling, or a decrease in use of analgesics compared to 
standard ice packs and is considered to be not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a left cryo ROM knee orthosis. Our 
reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found 
that the left cyro ROM knee orthosis exceeds the patient's medical need and is not medically necessary per the 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items 
or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The requested items exceed the patient's medical need as the 
documentation reveals this is not a simple orthosis but combines pneumatic compression with cold therapy. The request exceeds the patient's medical needs. The documentation does not reveal evidence on an objective 
physical exam postoperatively that the patient has completed the knee surgery and requires this ROM orthosis. 
Additionally, the request for an orthosis with cryotherapy exceeds the patient's medical need. The 
documentation is not clear why the patient is unable to use a simple at home ice pack. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a left cryo ROM knee orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a left cryo ROM knee orthosis (L1833).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump refill kit (A4220) provided on May 27, 
2021. 
 
You asked the Plan to pay for the infusion pump refill kit (A4220). The Plan denied your request. The Plan 
says CPT code J2278 has been overturned. The Plan also says that CPT code A4220 remains denied as bundled 
services are not eligible for separate payment. 
 
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 A4220 is refill kit for implantable infusion pump. 
 
  We find that CPT code A4220 is not supported in the medical record. Specifically, CPT code A4220 has a 
status indicator of P. This means that CPT code A4220 is considered bundled and not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the infusion pump refill kit (A4220) 
have not been met. Therefore, we decided that the Plan does not have to pay for the infusion pump refill kit 
(A4220) provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in 
IVAPS mode that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home mechanical ventilator. Our 
reviewer says that a home mechanical ventilator is not medically reasonable and necessary. The record 
indicates that you have chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease.  
 The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. You could be treated with a BiPAP machine with average volume-
assured pressure support (AVAPS) capability. Our physician reviewer found that your condition does not meet 
Medicare criteria for a home mechanical ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each 
additional 15 minutes (97811) provided August 19, 2021 to September 14, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that this treatment was for nerve pain in your 
left leg. The nerves were damaged during knee replacement surgery on 9/17/2017. You were told that the 
services should be covered. The Plan denied your request. The Plan says this service was not covered under the 
Plan benefits.  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan only covers acupuncture for chronic low 
back pain. Acupuncture for knee pain is not covered. Therefore, we decided that the Plan does not have to pay 
for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided August 
19, 2021 to September 14, 2021.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee's needs can be met at an alternate 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. Our 
physician reviewer found the enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. At the current functional mobility level, the 
enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack 
of medical complexity, and lack of acute rehab nursing needs and high functional mobility level. While the 
enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be 
safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF.) 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were provided so the claim 
should be paid. The Plan denied your request. The Plan says the rendering and referring providers are both out-
of-network providers and there was no approved authorization. Also, the services 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 laboratory services provided on September 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 31, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
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. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 May 31, 2021.