Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses (L1833x2) and suspension sleeves 
(L2397x2) provided August 22, 2022. 
 
You asked the Plan to pay for the orthoses. You say that this provider is qualified to bill this service. The Plan 
denied your request. The Plan says the Plan confirmed with outreach to the enrollee that this was an unsolicited 
outreach telephone call and that there is no evidence of an established relationship between the enrollee and the 
ordering physician. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have 
not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1833x2) and 
suspension sleeves (L2397x2) provided August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan has to waive the deductible for office visits provided on February 19, 2022, and 
March 4, 2022. 
 
You asked the Plan to waive the deductible for office visits. You say that the office visits were not the required 
length for what you were billed. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records showing the length of your office visit 
times. Therefore, we decided that the Plan has to waive the deductible for office visits provided on February 
19, 2022, and March 4, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 22, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider is a 
mental health counselor and not eligible for payment by the health Plan or original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on September 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 26, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider is a 
mental health counselor and not eligible for payment by the health Plan or original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 13, 2022, to 
August 11, 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 July 13, 2022, to August 
11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 2, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 2, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93010 provided on May 30, 2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that this claim is a duplicate of a previously 
submitted claim and was correctly denied. 
 
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 case file contains a lack of evidence of prior 
payment for code 93010 provided on the same date of service by the same provider. Based on this information, 
we decided that Medicare rules for coverage of procedure code 93010 have been met. Therefore, we decided 
that the Plan has to pay for procedure code 93010 provided on May 30, 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 pay for procedure code 99497 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that these services were medically necessary and 
appropriate. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for 
code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you are currently sleeping on a 
couch due to fibromyalgia and arthritis which has caused you a lot of pain. You walk bent over and the couch 
you are currently sleeping on is making it worse. You need the full electric hospital bed over a standard bed 
due to not being able to maneuver your body or lift yourself up. The Plan denied your request. The Plan says 
the requested bed is not covered as the height adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20553) provided on March 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with an inappropriate modifier. 
 
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 20553 is not supported in the medical record. Specifically, it is 
inappropriate to bill code 20553 with modifier -50 in this case. Code 20553 does not require a modifier to 
indicate laterality. 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 (20553) provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this service was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the services are not covered 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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation provided does not 
meet the criteria for coverage for the requested dental services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the dental services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on August 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and were 
reported appropriately. 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 (81455) provided on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 22, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the observation stay (CPT code 99218). 
 
You asked the Plan to pre-approve the observation stay. You say that the stay is necessary. The Plan denied 
your request. The Plan says that this is an administrative denial for the lack of submission of information 
needed for the Plan's clinicians to review your request for a medical necessity determination. 
 
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 pre-approve the observation stay. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee was stable and appropriate for observation level of care 
services after the emergency room evaluation on November 18, 2022. The enrollee did not require or receive 
any inpatient level of care services. The review has determined that the observation stay was necessary based 
on the information provided. 
 
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 observation stay have been met. Therefore, we decided that the Plan has to 
pre-approve the observation stay (CPT code 99218).  
 
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 humidifier (E0562) provided on March 10, 2022. 
 
You asked the Plan to pay for the humidifier. You say that this equipment was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a humidifier (E0562) provided on March 10, 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 services are medically necessary, the enrollee 
requires frequent rehabilitation physician visits and physical and occupational therapy. The Plan denied your 
request. The Plan says the enrollee can safely receive the services needed in other settings, such as a skilled 
nursing facility, home with home health and home physical therapy, 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 the enrollee does not require treatment by multiple therapies. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 15, 2021. 
 
You asked the Plan to pay for laboratory services. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness 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 September 5, 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 laboratory services 
provided on September 15, 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 enrollee can benefit and improve 
with LTACH services with an expected stay greater than 25 days. You say that the enrollee is stable and 
suitable for transfer and cannot be adequately cared for in their current condition at a skilled nursing facility as 
they require direct daily physician assessments. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a shower chair.