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

 
We decided that the Plan does not have to pay for the chiropractic services provided on November 8, 2021, 
through January 20, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the service should be covered. The Plan 
denied your request. The Plan says chiropractic services other the manipulations are not covered. 
 
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 the chiropractic services provided on November 8, 2021, through January 20, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided from October 25, 
2021, to October 28, 2021. 
 
You asked the Plan to pay for critical care. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says these services are not supported 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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing 
these services is not noted in the record. Without this information, it cannot be confirmed that 30-74 minutes of 
critical care were provided. Based on this information, we decided that Medicare rules for coverage of critical 
care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour 
(99291) provided from October 25, 2021, to October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services provided on December 10, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the procedures 
are inclusive to a more comprehensive procedure. 
 
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 75774 is angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure). The CPT Code Manual definition of code 75726 is Angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation. 
 
We find that the angiography services were provided as part of a vascular embolization procedure. Providers 
should not unbundle services that are integral to a more comprehensive procedure. 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 angiography services provided on December 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided on September 29, 
2021, through November 2, 2021. 
 
You asked the Plan to pay for the behavioral health services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says Mental Health Counselors are not eligible to participate in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided 
on September 29, 2021, through November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, per lens (V2781) provided on May 10, 
2021. 
 You asked the Plan to pay for the progressive lens. You say that you received cataract surgery on December 7, 
2020, and your eye doctor recommended new corrective lenses. You also say that the Plan covers eyeglasses 
post-surgery. The Plan denied your request. The Plan says your plan contract does not cover progressive lens. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. The record does 
not provide evidence that a cataract surgery involving the insertion of an intraocular lens was rendered prior to 
receiving the progressive lenses. Therefore, we decided that the Plan does not have to pay for the progressive 
lens, per lens (V2781) provided on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous spacer surgery. 
 
You asked the Plan to pre-approve the procedure. 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that interspinous spacer surgery is experimental. More research is needed to show safety and 
efficacy of this procedure. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve interspinous spacer surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 codes 88104, 88305, 88312, and 88361 are not supported in the medical record. Specifically, 
these codes have a PC/TC indicator of 1. In this case, the codes in question were not billed with the appropriate 
modifier for payment to be made. 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 the lab services 
provided on August 16, 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 IRF care is medically necessary as the enrollee is 
unsafe for home discharge and skilled nursing facility placement is an inadequate level of care. The Plan 
denied your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a 
lower level of care such as at a skilled nursing facility, on an intermittent basis at home with home health care, 
or in a long-term care setting. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) visits (97032, 97110, 97112, 
97035) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT visits. You say that you are requesting an authorization with an in-
network exception for outpatient PT. You also say that the provider is located on site at the enrollee's assisted 
living facility which is convenient for the enrollee. The Plan denied your request. The Plan says there are in-
network providers available for these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The records provided for review do not 
show that the services at issue are urgent or emergent. We found no exception that would require the Plan to 
pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy (PT) visits (97032, 97110, 97112, 97035) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis procedure provided on October 
31, 2021, and November 1, 2021. 
 
You asked the Plan to waive the coinsurance for dialysis procedure. You say that you should not have to pay 
this bill that you received on February 3, 2022. The Plan denied your request. The Plan says coinsurance 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 20% 
coinsurance for Medicare-covered renal dialysis.  
 
  You have been asked to pay $113.90, which is 20% of the allowed amount for the dialysis procedure. The 
allowed amount is $569.50 (20% x $569.50 = $113.90). Dialysis procedure falls within the Services to treat 
kidney disease 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 dialysis procedure 
provided on October 31, 2021, and November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulance transport (A0429, A0425) provided 
on September 28, 2021. 
 
You asked the Plan to pay for emergency ambulance transport. You say that the enrollee only had one transport 
on the date of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the claim at issue is a duplicate of a prior claim that was processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of emergency ambulance transport have not been met. Specifically, the Plan has documented that the 
claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does not have to pay for emergency ambulance transport (A0429, A0425) provided on September 28, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130) 
and non-emergency transportation, per mile (A0080) provided on January 12, 2022. 
 
You asked the Plan to pay for the transportation services. You say that the hospital advised they would arrange 
for your transport. You also say that you were not aware the transport would not be covered. The Plan denied 
your request. The Plan says that convenience transfers between skilled nursing facilities and hospitals, 
including any transportation, facility or physician charges associated with such are not covered for any 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.   
The services you have asked the Plan to pay for are wheelchair van transport services. Additionally, the record 
shows that you were not transported to the nearest facility. Therefore, we decided that the Plan does not have to 
pay for the non-emergency transportation: wheelchair van (A0130) and non-emergency transportation, per mile 
(A0080) provided on January 12, 2022.
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 
April 27, 2021, to May 10, 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 in the presence of incomplete support for sepsis 3, ICD-10 code A41.9 has been removed from 
the claim consistent with the documentation in the record. 
 
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 853 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE 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 even though sepsis is documented, supporting medical record 
documentation was not found within the record. The review has determined that the records did not support this 
DRG and use of the A41.9 (Sepsis, unspecified organism) diagnosis code.  
 
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 April 27, 2021, to May 10, 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 you had a bad fall and need inpatient rehabilitation. 
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You do not need 
an inpatient level of care as you do not need regular doctor visits (three or more times per week) to oversee 
your care and recovery, and you do not need three hours of daily therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility or at home with outpatient therapy services. 
 
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 while the enrollee may benefit from physical therapy, and occupational therapy, his rehab needs can be safely addressed at a low intensity alternate setting such as in a skilled nursing facility. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic procedure (code 76496) you received from a 
chiropractor on October 27, 2021. 
 
You asked the Plan to pay for the fluoroscopic procedure. You say that you had sought treatment from various 
specialists but your symptoms continued. You said that this provider was able to address your condition. The 
Plan denied your request. The Plan says this is not a covered procedure when received from 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 the fluoroscopic procedure (code 76496) you received from a chiropractor on 
October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 19, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 on August 19, 2021 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on July 1, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the physician services were urgently 
needed for the enrollee and there was no in-network provider at the facility. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no approved authorization. 
  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 nursing facility care provided on July 1, 2021, 
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 to the enrollee on May 28, 
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 records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services provided to the 
enrollee on May 28, 2021. have been met. The provider did not send in any evidence showing that the referring 
provider was actually treating the patient in this case. There is no physician order from the treating provider in 
this case.. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the 
enrollee on May 28, 2021.