Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, mechanical traction, and chiropractic 
manipulation (to regions other than the spine) provided by a chiropractor on January 17, 2022. 
 
You asked the Plan to pay for these services. You say that you were not aware these services would not be 
covered. The Plan denied your request. The Plan says the services in question are not covered under your 
contract under any normal circumstances when performed by a chiropractor.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit, mechanical traction, and chiropractic manipulation (to regions 
other than the spine) provided by a chiropractor on January 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99153) provided on February 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable for 
this place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
practice expense (PE) only code and is not paid to the physician in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT 
code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to 
pay for the services (99153) provided on February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital and found to have arterial occlusion, heart failure, and a urinary tract infection. The 
records show she is now responding to treatment with stable vitals approaching her baseline. She should only 
require short-term additional acute care services that can safely be completed at the current facility until more 
appropriate for a lower level of care. She does not require services at the LTACH that are not already available 
at the current facility. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary at this time as it 
would not be clinically advantageous. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that he enrollee needs LTACH to be able to 
reach their maximum function. The Plan denied your request. The Plan says there is no documentation that the 
enrollee would benefit from and improve with LTACH management and does not support a stay of at least 25 
days. 
 
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 patient appears to be stable and improving and should only require short-term 
additional acute care services that can safely be completed at the current facility until more appropriate for a 
lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary at this time as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 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 long term acute care hospital (LTACH) 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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient care at the current hospital. 
 
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 already 
available at the current facility. Completion of treatment at the current facility is recommended. 
 
 
  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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99282 and 99283 billed for date of service 
November 9, 2021. 
 
You asked the Plan to pay for procedure codes 99282 and 99283. The Plan denied your request. The Plan says 
payment for codes 99282 and 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 codes 
99282 and 99283 are column II codes 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 codes 99282 and 99283 billed for 
date of service November 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on March 31, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support an active diagnosis of chronic obstructive pulmonary disease (COPD, asthma, or chronic lung disease. 
The records do not support a nursing function of 6-14, or a Non-Therapy Ancillary (NTA) score of 2. 
 
We looked at this coder's review, the file, and Medicare rules. The records do not support the billing of PDPM 
score ODGE1. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services 
provided to the enrollee on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve glucose test strips to test six times per day. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that testing supplies beyond usual utilization limits 
are covered when specific criteria are met. 
 
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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the records show that you have Type II 
diabetes. You treat with Levemir and Novolog and the last blood sugar test showed a level of 5.8 on February 
17, 2021. The records do not support that the criteria for coverage of glucose test strips for testing six times per 
day are met and the services are therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve glucose test strips to test six times per day.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on March 9, 2022. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head/brain (70450-26) 
provided on October 15, 2021. 
 
You asked the Plan to pay for the CT scan. You say that this service is supported in the record. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid 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. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 19, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for computed tomography (CT) of the head/brain (70450-26) 
provided on October 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from March 26, 2022, to 
March 28, 2022. 
 
You asked the Plan to pay for the drugs. You say that you were not given any instructions regarding the cost of 
the prescription, and that it was not covered. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from March 26, 2022, to March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on January 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the remote monitoring services. You say that it is the facilities responsibility to 
obtain authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the remote monitoring services provided on 
January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services at issue in this appeal. The Plan did not pre-approve 
the laboratory services at issue. We found no exception that would require the Plan to pay for these laboratory 
services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 
25, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
You asked the Plan to pre-approve the Group 3 PWC. You say that this is a medically necessary PWC as the 
enrollee has paraplegia caused by a stroke. The Plan denied your request. The Plan says though stroke is noted 
by the physical therapist, this is not corroborated by the physician progress note on the date on which the order 
for this PWC was written. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to a neurological condition, myopathy, or congenital 
skeletal deformity. This diagnosis must be confirmed by contemporaneous medical records as noted in the 
Medicare rules section of this decisions.  We looked at the file and Medicare rules. The medical records submitted do not clearly document the history of 
stroke, nor of paraplegia caused by stroke. The order/prescription states these conditions exist; however, this is 
not considered part of the medical record without corroboration. The progress note for the date the order was 
written does not include stroke or paraplegia. The physical therapist note also documents a history of stroke, 
but though considered part of the contemporaneous record, there is not sufficient description of when the stroke 
occurred or that it is the primary cause of the mobility limitation. In order to support that the criteria for a 
Group 3 PWC are met, additional records corroborating the history of stroke/paraplegia being the cause of the 
mobility limitation are required. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (PWC) with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound supplies provided on December 10, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound supplies. You say that these are separately billable and do not require 
separate authorization. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
  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 wound supplies provided on December 10, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
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 clinical assessment does not support the expectation of a stay to be at 
least 25 days. 
 
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 appears to be stable and improving and should only require short-term 
additional acute care services that can safely be completed at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary at this time as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomographic angiography (CTA) (75574) 
provided on October 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CTA. You say that this service was medically necessary. The Plan denied 
your request. The Plan says out-of-network services are only covered in certain limited circumstances. The 
requested CTA was not urgent or emergent, and it was not pre-approved or referred by a network provider. 
 
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 computed tomographic angiography (CTA) 
(75574) provided on October 11, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 18, 2020. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says 
Medicare denies a claim if it is not received by the Plan within 12 months or 1 calendar year from the date 
when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an emergency department visit was not filed until March 17, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
August 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 13, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service March 13, 2022.