Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
27, 2021, to June 4, 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 DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the review has determined that DRG 871 was not appropriate in this case. DRG 
872: SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC was more 
appropriate in this case. Although the provider documented acute tubular necrosis (ATN), reasonable support 
within the medical record must be present for that diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 27, 2021, to June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377, K0108x4) for the enrollee. 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says this 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 the additional accessories. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided, there is no documentation that supports the 
medical necessity of the additional power wheelchair accessories (E2300, E2311, E2313, E2377, K0108x4) as 
defined by Medicare criteria.  The power seat elevation feature (E2300) is non-covered at it does not serve a primary medical purpose and is 
statutorily non-covered. The E2377 expandable controller, E2313 expandable controller harness and E2311 
electronic connection do not meet criteria for coverage as provided records document that the enrollee has 3-/5 
to 3/5 upper extremity strength and is independent with eating, thus indicating she has adequate upper 
extremity strength and function to operate the wheelchairs power options with their own switches. K0108x4 
are not covered as these are duplicate requests.  
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377, 
K0108x4) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on August 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 11, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 11, 
2021, 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 brand-specific Lymphacare pneumatic compression 
device (E0651, E0669) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation showing the specific features of this item that distinguish it 
from other available/preferred alternatives. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient documentation showing at least a four-week trial of conservative therapy. 
Additionally, there was no explanation found in the documentation describing why the Airos Lymphacare 
device would be specifically more appropriate for this patient over other brands. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a brand-specific Lymphacare pneumatic compression device (E0651, E0669) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 20, 2021. You asked the Plan to pay for the testing services. You say that the analysis supports optimal treatment 
planning. The Plan denied your request. The Plan says the testing does not meet reasonable and necessary 
requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The testing panel at issue included more than 6 pathogens. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on September 20, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on June 6, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says it is the 
responsibility of the provider to bill the primary plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer.  However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate 
their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary 
insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the 
Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
services provided until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the emergency room services provided on June 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre Continuous Glucose Monitor (CGM) and 
supplies provided on March 30, 2021. 
 
You asked the Plan to pay for the FreeStyle Libre CGM and supplies. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support that the enrollee's physician discussed a need for these supplies. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the documentation does not support that the enrollee's physician discussed the need 
for the billed supplies. 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 the FreeStyle 
Libre Continuous Glucose Monitor (CGM) and supplies provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) on September 16, 
2021. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 G0463 is not supported in the medical record. Specifically, a review of the file shows 
that the claim was not billed with condition code G0. Billing multiple medical visits in the same day requires 
this condition code. Based on this information, we decided that Medicare rules for coverage of a hospital 
outpatient clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for a hospital 
outpatient clinic visit (G0463) on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686), and addition (L2624), provided on 
September 16, 2021. 
 
You asked the Plan to pay for the hip orthosis and addition. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the medical records submitted do not support the items ordered. 
 
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, or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no evidence the treating physician discussed medical necessity for these items and the medical records do not show they are needed. 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 the hip orthosis (L1686), and addition (L2624), provided on September 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance (77003) provided May 6, 2021. 
 
You asked the Plan to pay for the fluoroscopic guidance. 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. In this case, we have confirmed that code the 
fluoroscopic guidance is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for fluoroscopic guidance (77003) provided May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cerebral perfusion analysis (0042T) provided on October 
30, 2021. 
 
You asked the Plan to pay for the cerebral perfusion analysis. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this service was not billed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 0042T is not supported in the record. Specifically, CPT code 0042T was billed with 
modifier 26. CPT code 0042T has a professional/technical component (PC/TC) indicator of 0 meaning that this 
is code for physician services and the concept of PC/TC does not apply since physician services cannot be split 
into professional and technical components. Modifier 26 is not appropriate. Based on this information, we 
decided that Medicare rules for coverage of the cerebral perfusion analysis have not been met. Therefore, we 
decided that the Plan does not have to pay for the cerebral perfusion analysis (0042T) provided on October 30, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on October 21, 2021. 
 
You asked the Plan to pay for therapeutic activities. You say that you have provided medical records to 
substantiate the service rendered. The Plan denied your request. The Plan says rules for payment have not been 
met because the claim was not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that modifiers are used to identify therapy services 
whether or not financial limitations are in effect. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapeutic activities have not been met. Specifically, CPT code 97530 is considered an always 
therapy code. This means that CPT code 97530 requires a modifier to indicate the discipline of the plan of 
care under which the service is delivered. CPT code 97530 was not billed with the required modifier and does 
not meet criteria for billing or reimbursement consideration. Therefore, we decided that the Plan does not have 
to pay for therapeutic activities (97530) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services 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 facet joint injections. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that the enrollee has multiple other probable pain generators and therefore does 
not meet the coverage criteria for performing medial branch blocks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you have a torn ligament, arthritis 
and you are afraid of falling. You also say the wheelchair is necessary. The Plan denied your request. The Plan 
says this device may be able to assist you with mobility. The Plan also says you are independent with your 
basic activities of daily living with the exception of bathing. You are able to walk with the use of your cane and 
four wheeled walkers with a seat. Additional assessment may be requested after you have completed bilateral 
knee surgeries and physical therapy. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The file also 
shows that you are able to walk with the use of your cane and four wheeled walkers with a seat. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle, group 1 standard (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 25, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on 
July 19, 2021. 
 
You asked the Plan to pay for the office visit. You say that the medical records support the service rendered 
and the claim should be processed for payment. The Plan denied your request. The Plan says this provider is 
not a participating provider with the Plan. 
 
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 
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 office visit provided by an out-of-network 
provider on July 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a trimming of dystrophic nails (G0127) and a paring of benign lesions 
(11056) provided on October 25, 2021. 
 
You asked the Plan to pay for a trimming of dystrophic nails and a paring of benign lesions. You say that you 
have provided records to support the services rendered. The Plan denied your request. The Plan says that rules 
for payment have not been met because the claim has been filed with a missing, incomplete, or invalid place of 
service (POS) code. 
 
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 has not substantiated their denial in this case. The records show that the 
services were provided when the enrollee was in a skilled nursing facility (SNF), and the claims summary 
shows that POS 31 was used. The Plan covered the SNF stay and the Plan has not offered an alternative POS to 
use in this case. Therefore, we decided that the Plan has to pay for a trimming of dystrophic nails (G0127) and 
a paring of benign lesions (11056) provided on October 25, 2021.  
 
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.