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

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6545 that 
were issued on September 28, 2021. 
 You asked the Plan to pay for the compression stockings. You say that the enrollee had active ulcers causing 
the need for the item billed. Medical records attached for review and to determine medical necessity. The Plan 
denied your request. The Plan says there is no documentation of a surgical wound or debridement. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6545 that were issued on September 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on June 8, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the plan's policy covers non-emergency ambulance transportation when it is the only 
way to safely and adequately transport a patient or if other means of transporting a patient are unsafe due to a 
medical condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 medically reasonable or necessary. Our physician reviewer found that 
transportation via ambulance from the enrollees residence to his hemodialysis appointment was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van) without endangering the enrollees condition. A prudent layperson would not believe that 
immediate medical attention was required for someone attending a scheduled appointment. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 12, 
2022. 
 
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 prior authorization was not 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 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 laboratory services provided to the enrollee on 
August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient diagnostic tests provided on 
June 9, 2022, to June 22, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient diagnostic tests. You say that you disagree with the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $750 
deductible for Section 2.1 Your medical benefits and costs as a member of the plan.  
 
You have been asked to pay a $750 deductible for outpatient diagnostic tests. The total amount you are being 
asked to pay towards your deductible is $580.87. This item/service falls within the Section 2.1 Your medical 
benefits and costs as a member of the plan 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 coinsurance 
for outpatient diagnostic tests provided on June 9, 2022, to June 22, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary in order to improve 
the enrollee's condition. The Plan denied your request. The Plan says that the role of this technology remains 
uncertain and investigational. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found bioimpedance spectroscopy for breast cancer related lymphedema assessment has become a standard of 
care for prevention and treatment. Clinical measurements are obtained initially to establish a baseline before 
breast cancer treatments and afterward at intervals to track changes during treatment. Alternatively, changes in 
arm circumference or volume relative to the contralateral normal limb can be performed. Given that the highest 
risk of developing lymphedema is within the first three years of treatment and that early intervention can limit 
progression of disease, high-risk patients should be followed closely in this period. Given the treatment his 
patient has received for her breast cancer she is at increased risk of lymphedema. The service was reasonable 
and medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy.  
 
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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that enrollee will require physical and 
occupational therapy to address de-conditioning while returning them to their previous level of functioning due 
to a prolonged hospital stay. You say that the enrollee demonstrates signs and symptoms of sufficient severity 
that their medical condition, safety, or health would be significantly threatened if managed in a lower level of 
care such as a skilled nursing facility. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be provided 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 requires acute care service before transitioning to a lower level of 
care. The enrollee does not require services that they are not currently receiving but that would be available at 
an LTACH. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided from April 5, 2022, to May 9, 2022. 
 
You asked the Plan to pay for inpatient services. You say that these services were necessary and were reported 
appropriately. The Plan denied your request. The Plan says that this claim needs to be corrected and 
resubmitted. 
 
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. Specifically, the Plan does not clarify or explain what information on this claim 
needs to be corrected. Without this information, the Plan's denial cannot be verified. Therefore, we decided that 
the Plan has to pay for inpatient services provided from April 5, 2022, to May 9, 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
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 is a 57-year-old female who was admitted to the acute care hospital 
with duodenal bleed requiring embolization/cautery complicated by hemorrhagic shock due to blood loss 
anemia requiring fluids, blood transfusions and further complicated by acute on chronic respiratory failure with 
pneumonia, congestive heart failure, and chronic renal failure requiring intubation and antibiotics. Recent notes 
describe the enrollee with fevers and still dependent on mechanical ventilation support without clear ability to 
wean at this time. The enrollee appears to be currently unstable and should only require short-term additional 
acute care hospital services that can safely be provided at the current facility until more stable and 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 the LTACH is not medically necessary as the enrollee is too unstable for 
transfer at this time and 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on May 12, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the enrollee was seen twice on the 
same date of service at two different times. 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 June 2, 2022. 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 emergency department visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on May 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82656, 82705 and 83993) provided on 
March 21, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary. The Plan denied 
your request. The Plan says the CLIA number on this claim is invalid. This claim cannot be processed until this 
number is corrected. 
 The Plan must follow Medicare rules. Medicare rules say that any independent laboratory performing tests 
covered by CLIA must submit the CLIA number on the claim. Laboratory claims submitted without the 
required CLIA number are returned as unprocessable. If the CLIA number is submitted on the claim, but is 
inconsistent with the CLIA format, the A/B MAC (B) returns the claim as unprocessable. 
 
We looked at the file and Medicare rules. The CLIA number submitted on this claim is invalid. Based on this 
information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, 
we decided that the Plan does not have to pay for laboratory services (82656, 82705 and 83993) provided on 
March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17261 and 12032 billed for date of service 
January 25, 2022. 
  You asked the Plan to pay for procedure code 17261 and 12032. The Plan denied your request. The Plan says 
the submitted medical records do not indicate that procedure code 17261 was performed. The Plan also says 
procedure code 12032 is considered inclusive to procedure code 17261 and cannot be separately reimbursed. 
 
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 17261 is destruction, malignant lesion (eg, laser surgery, 
electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 
1.0 cm. The CPT Code Manual definition of code 12032 is repair, intermediate, wounds of scalp, axillae, trunk 
and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm. 
 
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 17261 and 12032. Our reviewer says that the 
medical records provided do not include sufficient documentation to validate that destruction, malignant lesion, 
trunk, arms or legs; lesion diameter 0.6 to 1.0 cm was performed. Our reviewer also found that procedure code 
12032 has a bundled relationship with procedure code 17621. The medical records provided do not confirm 
that procedure code 12032-59 was performed as a distinct service. Therefore, it is inappropriate to use modifier 
59 on procedure code 12032 and additional reimbursement is not allowed. 
 
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 17261 and 12032 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 17261 and 12032 billed for date of service January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 provided on December 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 25, 
2022. 
 
You asked the Plan to pay for SNF care. You say that the admission and care were medically necessary for the 
enrollee. The Plan denied your request. The Plan says the SNF admission was 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 pay for SNF care. Our reviewer says that the SNF 
care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Specifically, the provided documentation from the 
enrollee's inpatient hospital stay is not sufficient to support that skilled nursing facility (SNF) services were 
necessary for the enrollee. The file shows that the Plan requested medical records from the SNF stay, but none 
were received. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care 
provided from March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness 
(E2313), an expandable controller (E2377) and a tray hardware (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the seat elevator does not service a medical purpose. The upgraded 
electronics (expandable controller, harness, and electronic connector to 2 power options) are not medically 
necessary and cannot be covered. The tray hardware is included with the approved tray. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The seat elevator in this appeal does not serve a purpose that is primarily medical in nature. The tray hardware 
is included with the approved tray. Although there are two approved power options on this wheelchair, there is 
not a medical need to control these power options through the joystick. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (E2300), an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), a harness (E2313), an expandable 
controller (E2377) and a tray hardware (K0108).