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

 
We decided that the Plan does not have to pay for Inpatient hospital care billed with code 93460-56-59 
provided on April 28, 2022. 
 
You asked the Plan to pay for impatient care provided. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says documentation does not support the billed code.  
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 93640 is a column II code to column I code 92928; however, 93640 
was billed with a modifier.  
 
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 impatient care provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the record does not support that the 
cardiac catheterization reported with 93460 is a separately identifiable and medically necessary 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 impatient care provided. have not been met. Therefore, we decided that the Plan 
does not have to pay for Inpatient hospital care billed with code 93460-56-59 provided on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that you did consider bilevel positive airway 
pressure however you think that the enrollee needs volume targeted ventilation otherwise known as volume 
assured pressure support with a backup rate to ensure that the desired minute ventilation. The Plan denied your 
request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS mode with Auto-EPAP 
(AE) 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 the ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe COPD, documented with pulmonary function tests in 2022. The 
enrollee was seen as an outpatient on January 5, 2023. Arterial blood gas done on that date showed mild 
hypercapnia. This enrollee may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. A home ventilator 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test. 
 
You asked the Plan to pre-approve a Cologuard test. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan must follow Medicare rules. Medicare rules say that CologuardTM test is covered once every three 
years for Medicare beneficiaries that meet certain criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cologuard test have not been met. Specifically, you are beyond the age range recommended. 
Therefore, we decided that the Plan does not have to pre-approve a Cologuard test.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the cost share for an injection provided on September 8, 2022. We decided that the Plan does not have to waive the cost share for the cardiovascular stress test and lab services provided on September 8, 2022.

You asked the Plan to waive the cost share for a cardiovascular stress test, a rubidium injection, and laboratory services provided on September 8, 2022. You say that you did not know the provider was out-of-network. The Plan has denied your request. The Plan says that the cost sharing applied correctly.

We decided that the Plan has to waive the cost share for an injection provided on September 8, 2022.

You have been asked to pay $122.95 for the injection. According to Medicare, a regadenoson injection (code J2785) is considered a packaged code and excluded from the physician's fee schedule and you cannot be charged for this service. Therefore, we decided that the Plan has to waive the cost share for the injection provided on September 8, 2022.

We also decided that the Plan does not have to waive the cost share for the cardiovascular stress test and lab services provided on September 8, 2022.

You have been asked to pay $392.86 towards your deductible for the stress test and lab services. These items/services fall within the outpatient diagnostic tests and services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to OON outpatient diagnostic tests and lab services. This cost sharing is a contractual obligation that had not been met at the time the stress test and lab services were received on September 8, 2022.

You have been asked to pay 50% coinsurance after your remaining deductible was satisfied for an exercise stress test. You have also been asked to 50% coinsurance of the allowed amount for the office visit, lab services, and pharmaceutical agent provided on September 8, 2022. These items/services fall within the physician/practitioner services and outpatient diagnostic tests and services benefit categories. Therefore, we decided that the Plan does not have to waive the cost share for the cardiovascular stress test and lab services provided on September 8, 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: ER
Decision: Partially Favorable

 
You asked the Plan to pay for an emergency room visit and electrocardiogram (EKG) provided on June 11, 
2022. You say that the enrollee was seen twice on the same date of service by two different providers. The Plan 
says that these services were already paid on a different claim, so duplicate payment is not supported. 
 
We decided that the Plan has to pay for EKG.  
 
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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Plan states that this EKG was already billed for 
the same date of service by the same provider; however, the claim for the same date of service was billed by a 
different physician. Based on this information, we decided that Medicare rules for coverage of EKG have been 
met. Therefore, we decided that the Plan has to pay for EKG.  
 
We also decided that the Plan does not have to pay for emergency room visit. 
 
The Plan follows Medicare rules. Medicare rules state that if more than one evaluation and management service 
is provided on the same day to the same patient by more than one physician in the same specialty and group, 
only one evaluation and management service may be reported unless they are for unrelated problems. 
 
The record shows that this evaluation and management service was performed for a related problem to an 
evaluation and management service performed on the same date of service by another physician of the same 
specialty group practice which was already paid by the Plan. Therefore, we decided that the Plan does not have 
to pay for emergency room visit. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services (G0127) provided on August 24, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code G0127 is not supported in the medical record. Specifically, the claim was not billed 
with the required anatomical modifiers. Based on this information, we decided that Medicare rules for coverage 
of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for 
podiatry services (G0127) provided on August 24, 2022.
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 physical and occupational therapy 
to return to prior level of care and minimize re-hospitalization. The Plan denied your request. The Plan says 
under Medicare, the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing the denial. The Plan 
denied your request. The Plan says there is no documentation that all the criteria has been met. 
 
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 the SSBCI benefits. Our reviewer says 
that the SSBCI benefits are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have chronic obstructive pulmonary disease (COPD). You are not dependent on oxygen 
support and have had no recent hospital stay or emergency department visit on record. Your vitals were stable 
and physical examination unremarkable. The provided records do not show that you met all three criteria. You do not have a qualifying comorbid or medically complex condition, a life-threatening condition or one that 
significantly limits their health or function, and you do not require intensive care management at a high risk for 
hospitalization. 
 
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 SSBCI benefits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept device. 
 
You asked the Plan to pre-approve an Intracept device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept device.
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 you are requesting a reconsideration for the 
member's denied IRF admission. The Plan denied your request. The Plan says the member does not meet the 
Medicare criteria for an IRF admission. 
 
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 treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth 
#29 and #30. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat and are in constant pain. 
You say you need the two extractions to get your bottom dentures. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on March 13, 2023. The Plan approved six 
extractions which is the limit per calendar year. Therefore, we decided that the Plan does not have to pre-
approve the surgical removal of erupted tooth (D7210) for tooth #29 and #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that  the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with auto-
titration (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with average 
volume assured pressure support (AVAPS) and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on April 11, 2022. 
 
You asked the Plan to pay for the transport. You say that this is medically necessary. The Plan denied your 
request. The Plan says these services are not covered by Medicare.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 transport. Our reviewer says that the re 
Our physician reviewer found that the enrollee was evaluated for abdominal pain in the setting of known 
advanced-stage liver cancer. She was found to have a likely biliary obstruction due to the cancer. While 
transfer to a facility with appropriate services to treat the enrollee was reasonable, the use of an air ambulance 
was not. The enrollee was overall stable. The enrollee's cancer was chronic. The use of a ground ambulance 
would not have placed her at undue risk. Therefore, the use of an air ambulance was not medically necessary or 
reasonable. 
 
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 transport have not been met. Therefore, we decided that the Plan does not 
have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on April 
11, 2022.