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

 
We decided that the Plan does not have to pay for lab services provided on October 14, 2021. 
 
You asked the Plan to pay for the lab services. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on April 28, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that you are out-of-network, but the enrollee cannot choose 
which radiologist reads their diagnostic test. You say you are asking for reconsideration for payment. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 x-
ray. We found no exception that would require the Plan to pay for the x-ray. The records provided for review 
do not show that the x-ray was urgent or emergent. Therefore, we decided that the Plan does not have to pay for 
the x-ray provided on April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service March 26, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service March 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hernia repair/debridement and tissue transfer surgery. 
 
You asked the Plan to pre-approve surgery services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this surgery is not medically necessary for you. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery services. Our reviewer says that 
you do not meet the Medicare criteria for this procedure. Our reviewer found you have abdominal scarring 
from previous surgery with the presence of an asymptomatic umbilical hernia. The record does not indicate any 
functional impairment. This surgery is being requested for cosmetic reasons. The records provided do not 
establish the medical necessity of this surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hernia repair/debridement and tissue transfer surgery.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation shows that the enrollee has active medical conditions that would require close 
medical supervision. The evaluating therapists state that the enrollee requires intense and multi-disciplinary 
rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 waive the copayment for inpatient stay provided on March 5, 2022, 
to March 8, 2022. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you never asked to be in a private 
room, therefore you should not have to pay the charges. The Plan denied your request. The Plan says the 
copayment is correct. 
 
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 $310 
copayment for each day, for days 1-6 and a $0 copayment for each additional day, for each Medicare-covered 
hospital stay.  
 
  You have been asked to pay $930 for the inpatient stay ($310/day x 4 days = $930). The inpatient stay falls 
within the Inpatient Hospital Care 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 
inpatient stay provided on March 5, 2022, through March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 3, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that the history and physical, anesthesia record 
and operative report have been submitted. You say that the claim should be reviewed and allowed for payment. 
The Plan denied your request. The Plan says procedure code 00537 has been paid and procedure code 99100 is 
considered bundled and not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service February 28, 
2021. 
 
You asked the Plan to pay for procedure code 99292. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99292 is bundled into payment for code 36556. 
 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 99292 
is a column II code to column I code 36556. 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 99292 billed for date of service February 28, 
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro brace. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided and current clinical guidelines there is no documentation that 
the MyoPro Motion G Orthotic device at issue in this case meets Medicare criteria for medically reasonable 
and necessary per Social Security Act, Section 1862(a)1(A). Current clinical guidelines designate robotic 
therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" 
with unproven benefit in the home environment. In addition, the provided records report left upper extremity 
spasticity which may be a contraindication to use of the device. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myopro brace.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
refused ambulance transportation to the hospital because you could not leave your husband. You also say that 
you are on a limited income. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH can properly take care of the 
enrollee's current medical needs. The Plan denied your request. The Plan says that records do not show that the 
enrollee needs continued treatments and care that can only be given in a hospital 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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be administered 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. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extension of cervical fusion to T4, and inpatient 
admission. 
 
You asked the Plan to pre-approve extension of cervical fusion to T4, and inpatient admission. You say that the 
requested service is medically necessary. The Plan denied your request. The Plan says the service at issue is 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 extension of cervical fusion to T4, and 
inpatient admission. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation of neurologic 
dysfunction or spinal instability. There is no documentation of severe clinical deformity causing functional 
impairment. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extension of cervical fusion to T4, and inpatient admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve extension of cervical fusion to T4, and 
inpatient admission.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822-26 billed for date of service December 
27, 2021. 
 
You asked the Plan to pay for procedure code 95822-26. You say that these services were billed correctly and 
should be paid. The Plan denied your request. The Plan says code 95822-26 is not supported in the medical 
record. There is a more appropriate code (code 95955) that should have been billed instead. 
 
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 95822 is Electroencephalogram; recording in coma or 
sleep. 
 
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 procedure code 95822-26. Our reviewer says that code 
95822-26 is not supported in the medical record. Our reviewer found electroencephalogram (EEG) recording during non-intracranial surgery is documented, and therefore EEG recording in coma or sleep is incorrect code 
to report for service provided.  There is a more appropriate code to report for service documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95822-26 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95822-26 billed for date of service December 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are 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 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 an office visit provided on March 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided January 
6, 2022, to January 26, 2022. 
 
You asked the Plan to pay for the PCD. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the enrollee did not meet criteria for the device rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD identified with code E0675 is only 
covered for the use with peripheral artery disease. 
 
We looked at the file and Medicare rules. The PCD provided is only covered for a diagnosis of peripheral 
artery disease. A diagnosis of peripheral artery disease was not submitted on the claim. Based on this 
information, we decided that Medicare rules for coverage of the PCD have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided January 6, 
2022, to January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership purchased on January 1, 2019. 
 
You asked the Plan to pay for the health club membership. You say that you are covered for a fitness benefit 
and should be reimbursed through your account. The Plan denied your request. The Plan says you did not 
submit your reimbursement request within the required time frame. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the reimbursement requests is received by the Plan no later than March 31st of the following year. 
 
The Plans rules for coverage of gym benefits have not been met because your reimbursement request for the 
2019 plan year was received by the Plan on April 18, 2022, which is past the required time frame. Therefore, 
we decided that the Plan does not have to pay for the health club membership purchased on January 1, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.