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

 
We decided that the Plan does not have to pay for urological services provided to the enrollee on April 14, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no additional documentation supporting an additional service which was billed 
and remains denied. 
 
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 50433 is "Placement of nephroureteral catheter, 
percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, 
ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, new access." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records do not support payment 
for more than one unit of CPT 50433 on 4/14/21. The records do not support that CPT 50433 was rendered 
twice on this date of service. 
 
We looked at this coder'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 urological services provided to the enrollee on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0554).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has 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 that the requested admission to a SNF does not meet 
criteria. 
 
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 
service is medically necessary. Our physician reviewer found you require skilled therapy services, the 
specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
treatment. The available documentation supports that it is medically reasonable and necessary to provide 
skilled therapy services on a daily basis, on an inpatient basis, in a skilled nursing facility 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the services. We decided that the Plan does not have to pre-
approve the MRI of the leg.  
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan says that the 
current evidence does not support these procedures in this clinical scenario. 
 
We decided that the Plan has to pre-approve the MRI of the lumbar spine.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 for MRI of the lumbar spine. Our reviewer says that 
since occasionally lumbar spine pathology may be present with groin pain and weakness, this MRI is a 
reasonable request and should be approved. Our physician reviewer found that the enrollee has left lower 
extremity weakness and groin pain. The left groin and left hip would have been included in the field of view of 
the computed tomography (CT) of the abdomen and pelvis and no abnormality in this area was reported. 
 
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 the MRI of the lumbar spine.  
 
We also decided that the Plan does not have to pre-approve the MRI of the leg. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of the leg. Our reviewer says that the requested 
MRI of the lower extremity at this point has not been demonstrated to be medically necessary. Our physician 
reviewer found that the bilateral lower extremity doppler revealed no deep vein thrombosis. The CT scan of the 
abdomen and pelvis revealed cirrhosis and nothing otherwise of note. The left hip x-ray was negative. The 
neurological exam was negative. The enrollee had a course of physical therapy while hospitalized but follow-
up after discharge is not substantiated. 
 
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 MRI of the leg have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MRI of the leg. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided on 
January 11, 2021. 
 
You asked the Plan to pay for hospital discharge day management services. The Plan denied your request. The 
Plan says Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, 
covers all hospice care from the effective date of election to the date of discharge or revocation. During the 
election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal 
illness until the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management services provided on 
January 11, 2021.
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 does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services, the 
specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide 
treatment. The documentation does not support that it is medically reasonable and necessary to provide skilled 
therapy services on a daily basis, on an inpatient basis, in a skilled nursing facility 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. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (CPT code L3960) 
provided on August 11, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the dates do not match for the claim and proof of delivery. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthosis have not been met. The date of service August 11, 
2021, on the claim does not match the Proof of Delivery. Per Centers for Medicare & Medicaid Services 
(CMS), suppliers may use the shipping date as the date of service (DOS) or suppliers may use the date of 
delivery as the DOS on the claim. Therefore, we decided that the Plan does not have to pay for the shoulder 
elbow wrist hand orthosis (CPT code L3960) provided on August 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van services 
provided on September 17, 2021. 
 
You asked the Plan to pay for non-emergency transportation, wheelchair van services. You say that that the 
social worker advised you that wheelchair transport would be covered under your plan. The Plan denied your 
request. The Plan says transport by wheelchair van or ambulette and trips to or from a physicians office 
are not covered under any condition by Medicare. 
 
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. Therefore, we decided 
that the Plan does not have to pay for non-emergency transportation, wheelchair van services provided on 
September 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 18, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services you received on August 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Covered store and forward telehealth services are 
billed with the GQ modifier, via asynchronous telecommunications system. By using the GQ modifier, 
the distant site physician/practitioner certifies that the asynchronous medical file was collected and transmitted 
to them at their distant site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii.  
 
We looked at the file and Medicare rules. In this case, the telehealth services in question were billed incorrectly 
with the -GQ modifier by the non-contract provider. 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 the 
telehealth services you received on August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary and 
reasonable. The Plan denied your request. The Plan says the enrollee does not have complex nursing or medical 
needs requiring a resource intensive inpatient hospital 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 there are no acute rehab or nursing needs identified or documented in the record. 
While the enrollee may benefit from physical and occupational therapy, the enrollee does not need intensive 
therapies with a multidisciplinary approach to daily therapy in an IRF. The enrollee's rehab can be safely 
provided at a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 20, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on November 22, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you have coverage, and it should be 
covered. The Plan denied your request. The Plan says a limited oral evaluation is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided by a participating provider on November 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on July 20, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that your wife called 
911 when she found you passed out on the bathroom floor and by the time the ambulance arrived you had 
recovered. You say the Emergency Medical Technicians did a medical checkup and determined that a trip to 
the hospital was not necessary. You say that you were dehydrated because you were preparing for a scheduled 
colonoscopy to be performed within the hour and your wife drove you to the hospital. The Plan denied your 
request. The Plan says Original Medicare does not cover ambulance services if youre not transported. This 
means that we wont pay for ambulance services, including treatment performed, if one is dispatched for you 
and youre not transported. 
 
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 July 20, 2021. 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 ambulance response and treatment, no transport 
(A0998) provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0483) 
provided on September 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory services. Our reviewer found the review 
indicates that CPT code(s) 80307 and G0483 (1 unit) remains not supported. The documentation submitted did 
not include a physicians order of drug test(s), presumptive, any number of drug classes, any number of devices 
or procedures; by instrument chemistry analyzers; therefore, the billed service cannot be verified. The review 
has determined that the services are not supported by the medical records provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0483) provided on September 15, 
2021.