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

 
We decided that the Plan does not have to pay for the laboratory services coded 81223, 81225, 81226, 81227, 
81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81350, 81400, 81401, 81406, 81408 and, 
81479 provided on January 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT codes 81223, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81335, 81350, 81400, 81401, 81406, 81408 and, 81479 are not supported in the medical record. 
Specifically, only a single procedural code should be reported for these services. If there is no code that 
describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. Review of the file shows that more than one code was billed for the services provided. 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 coded 81223, 81225, 
81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81350, 81400, 81401, 81406, 
81408 and, 81479 provided on January 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you need this second opinion. The Plan denied 
your request. The Plan says that there are network providers available. 
 
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. 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 
a consultation to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
November 11, 2021, to November 21, 2021. 
 
You asked the Plan to pay for the SNF care. You say that you were led to believe that your second appeal 
would be granted. You say that you believed you would have time to have the enrollee moved to a different 
facility. You also say that you are extremely unhappy and dissatisfied with the way the plan has handled this 
situation. The Plan denied your request. The Plan says the enrollee did not receive daily skilled care on the 
dates of service in this case. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility (SNF) care provided from November 11, 2021, to November 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec ODT 75mg disintegrating tablet for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nurtec ODT 75mg 
disintegrating tablet for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
December 10, 2021. 
 
You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that to allow only one lifetime 
abdominal aortic aneurysm (AAA) screening severely limits any member with a family history, such as your, 
from taking proper care of their health. You also say that upon review of your family history, Original 
Medicare agreed to cover an AAA ultrasound every 2 years. The Plan denied your request. The Plan says you 
have exceeded the limits set in the subscriber's agreement. 
 The Plan must follow Medicare rules. Medicare rules say that ultrasounds are covered when medically 
reasonable and necessary. The plan contract states that ultrasound of the abdominal aorta is allowed once per 
lifetime. 
 
We looked at the file and Medicare rules. The contract says that you are allowed a one-time (once per lifetime) 
abdominal aortic aneurysm screening ultrasound. The record shows that you received an abdominal aortic 
aneurysm screening on July 19, 2019 and your abdominal aortic aneurysm screening benefit has been 
exhausted. Based on this information, we decided that Medicare rules for coverage of the ultrasound of the 
abdominal aorta have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound 
of the abdominal aorta (76706) provided on December 10, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient physical and occupational therapy (PT/OT) provided in 
the skilled nursing facility (SNF) from November 12, 2021, through November 22, 2021. 
 
You asked the Plan to pay for the SNF outpatient therapy. You say that this claim is incorrectly denying for 
incorrect dates. The denied dates are within the date range of the claim and should be paid. The Plan denied 
your request. The Plan says that field 31, 32, 33, and 34 of the Claim Form, the provider documented the 
occurrence date as 11/12/2021. However, the claim bills for other dates which is not properly documented. 
Therefore, this claim was denied due to incorrect coding. 
 
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 provided a valid denial rationale. The rationale given states that 
because the occurrence dates reported in fields 31-34 are November 12, 2021, the other dates cannot be paid. 
The Plan has cited no specific rule to support this determination.  
 
Review of the claim form shows that the fields at issue report the date of November 12, 2021, for occurrence 
codes 44, 17, 29, and 35. Respectively, these codes indicate the: Date Treatment Started for Occupational 
Therapy, Date Outpatient Occupational Therapy Plan Established or Last Reviewed, Date Outpatient Physical 
Therapy Plan Established or Last Reviewed, and Date Outpatient Physical Therapy Plan Established or Last 
Reviewed. We find that reporting this date for these occurrence codes is appropriate and valid given that PT 
and OT were provided starting on November 12, 2021, then on several other dates of service, including 
November 22, 2021. We find no issue with the values in these fields that would warrant denial of payment. 
This denial has not been substantiated. Therefore, we decided that the Plan has to pay for the outpatient 
physical and occupational therapy (PT/OT) provided in the skilled nursing facility (SNF) from November 12, 
2021, through November 22, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Face Down Recovery System purchased on December 
10, 2021. 
 
You asked the Plan to pay for these services. You say that  The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. 
 
The item at appeal is a Face Down Recovery System. While this item may be of benefit to you, it is not 
covered by Medicare or the Plan because it is precautionary in nature. Therefore, we decided that the Plan does 
not have to pay for the Face Down Recovery System purchased on December 10, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 8, 2022, to 
February 13, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission was medically 
necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights and medically 
necessary care did span greater than two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 8, 2022, to February 13, 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0427) and ground mileage 
(A0425) provided on December 2, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that the 
enrollee's transport was emergent and would not be included in the skilled nursing facility billing and/or 
inpatient stay billing. The Plan denied your request. The Plan says that these services are not covered when the 
enrollee is inpatient. 
 
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. We find that the evidence provided clearly indicates that this enrollee was not an 
inpatient at the time of transport, and the Plan failed to provide any evidence to support the enrollees inpatient 
status. Therefore, we decided that the Plan has to pay for the emergency ambulance transportation (A0427) and 
ground mileage (A0425) provided on December 2, 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel rendered on March 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
rendered on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a noninvasive osteogenesis stimulator. 
 
You asked the Plan to pre-approve a noninvasive osteogenesis stimulator. You say that osteogenesis 
stimulators are covered under the Durable Medical Equipment benefit. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that noninvasive stimulator devices are only covered 
for failed fusions where a minimum of 9 months has elapsed since the last surgery.  
 
We looked at the file and Medicare rules. The records show that your fusion surgery was on June 2, 2022. This means that 9 months have not elapsed since the last surgery. Based on this information, we decided that 
Medicare rules for coverage of a noninvasive osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a noninvasive osteogenesis stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99213), chiropractic 
manipulative treatment (98941), and massage therapy (97124) provided on March 4 to March 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office or other outpatient visit, chiropractic manipulative treatment, and 
massage therapy. You say that the services at issue were a medical necessity for the enrollee. The Plan denied 
your request. The Plan says rules for payment for out-of-network care have not been met. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit (99213), 
chiropractic manipulative treatment (98941), and massage therapy (97124) provided on March 4 to March 16, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from 
October 19, 2021, to October 27, 2021. 
 You asked the Plan to pay for the SNF admission. You say that the admission was medically necessary. The 
Plan denied your request. The Plan says the enrollee did not receive daily skilled care. 
 
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 the SNF admission. Our reviewer says that 
the enrollee did not meet the Medicare criteria for SNF care. 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) admission provided from October 19, 2021, to October 
27, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of SNF care from July 2, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF 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 physician reviewer 
found you qualified for ongoing SNF coverage on July 1, 2022. You had documented skilled nursing needs.  
You are receiving daily wound care to multiple wounds, which you cannot see, reach or tend to yourself. You 
do not have documented skilled therapy needs. Daily skilled nursing services are required to prevent 
deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have 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 continuation of 
SNF care from July 2, 2022, forward.  
 
 
 
 
 
 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete pelvic ultrasound (76856) provided on October 1, 
2021. 
 
You asked the Plan to pay for a complete ultrasound. You say that this service is supported as billed. The Plan 
denied your request. The Plan says the code billed is not appropriate for the service provided. The Plan says 
that code 76857 more accurately describes the service at issue. 
 
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 76856 is ultrasound, pelvic (nonobstetric), real time with image documentation; complete. 
 
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 a complete ultrasound. Our reviewer says that in this case, 
there is a more appropriate code to report for the documented service. Our reviewer found code 76856 is a 
complete evaluation and must minimally include: Female: description and measurements of the uterus and 
adnexal structures, measurement of the endometrium and bladder, and a description of any pelvic pathology. 
The medical record does not support a complete pelvic ultrasound per Medicare guidelines. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a complete ultrasound have not been met. Therefore, we decided that the Plan 
does not have to pay for a complete pelvic ultrasound (76856) provided on October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the ESRD payment. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $120 copayment for an emergency room visit on March 
22, 2022. 
 
You asked the Plan to waive the $120 copayment an emergency room visit on March 22 2022. You say that the 
enrollee should not be responsible for a copayment because you feel no care was received. The Plan denied 
your request. The Plan says the enrollee is responsible to pay a $120 copayment for each emergency room visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $120 copayment for Emergency Care.  
 
The enrollee has been asked to pay a $120 copayment for an emergency room visit. An emergency room visit 
falls within the Emergency Care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $120 
copayment for an emergency room visit on March 22, 2022.