Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from November 5, 2021, 
through December 16, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says these services were provided by a 
non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, these services were performed by a licensed 
acupuncturist not under the proper supervision as required by Medicare rules. Therefore, we decided that the 
Plan does not have to pay for the acupuncture services provided from November 5, 2021, through December 
16, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on September 2, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says that the submitted documentation 
did not include a valid physician order. 
 
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. While the Plan has denied payment stating that there is no valid physician order, 
the documentation clearly includes a physician order. There is no argument made by the Plan as to why this 
should be considered invalid for the purposed of payment. Therefore, we decided that the Plan has to pay for 
the genetic testing services provided on September 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 Genesight Psychotropic testing panel provided on October 
22, 2021. 
 
You asked the Plan to pay for Genesight Psychotropic testing panel. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is not sufficient 
evidence to support this testing is medically necessary. 
 
 The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Therefore, we 
decided that the Plan does not have to pay for Genesight Psychotropic testing panel provided on October 22, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting coverage for removable foot 
inserts due to right heel pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have safety concerns. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient care provided from February 12, 2021, through February 
18, 2021, as billed with the principal diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient care as billed. You say that you would like this claim paid as 
originally billed based on the Medicare rules. The Plan denied your request. The Plan says that the inpatient 
care has not been billed correctly per the medical documentation. 
 
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 principal diagnosis code, A41.9, defined as Sepsis, 
unspecified organism. 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 inpatient care as billed. 
Our reviewer says that the documentation supports the original billing of the principal diagnosis code A41.9 
defined as Sepsis, unspecified organism. Our physician reviewer found that the enrollee is a 74-year-old 
woman with a history of heart disease, chronic obstructive pulmonary disease (COPD), lung cancer, and 
hypertension, who presented to the hospital with shortness of breath. The enrollee was not in acute distress. 
Vital signs were stable. Lactic acidosis, elevated C-reactive protein test, and leukocytosis were noted. Imaging 
revealed prominent interstitial opacities in the right lower lobe without focal consolidation or effusion. The 
enrollee was admitted to the hospital on February 12, 2021, with suspicion of sepsis, acute-on-chronic 
bronchitis, and COPD. An intravenous fluid bolus and antibiotics were administered. Lactic acid level 
normalized hours later. Blood cultures were negative. In this case, the documentation in the case file supports 
the diagnosis of sepsis as defined by Medicare. The enrollee's clinical presentation and laboratory evaluation 
support the diagnosis. The documentation supports the billing of principal diagnosis code A41.9 used to bill 
DRG 871. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient care provided from February 12, 2021, through February 18, 2021, as billed with the principal 
diagnosis code A41.9.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a podiatry office visit and X-rays of the foot 
provided on January 19, 2022. 
 
You asked the Plan to waive the deductible for the office visit and X-rays. You say that you were in a great 
deal of pain and would like this claim to be paid. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $110 deductible which applies to certain items and services.  
 
The services you asked the Plan to waive the deductible for fall within the Podiatry Services and Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit categories. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is $110 deductible which applies to certain items and 
services. This cost sharing is a contractual obligation that had not been met at the time the office visit and X-
rays were received on January 19, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for a podiatry office visit and X-rays of the foot provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient hospital visits provided on 
January 5, 2022, and January 12, 2022. 
 
You asked the Plan to waive the deductible for outpatient hospital visits. You say that you are being billed for a 
hospital service but you did not get any benefits of a hospital. The Plan denied your request. The Plan says the 
deductible applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $200 deductible which applies to outpatient hospital services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Hospital Services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time outpatient hospital visits were received on January 5, 2022, and January 12, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for outpatient hospital visits 
provided on January 5, 2022, and January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 16, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you met your out-of-pocket 
maximum and should not be charged. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $30 
copayment for each specialist visit.  
 
The file shows that your out-of-pocket maximum had not been met at the time this claim was processed. Please 
note that amounts are applied toward this maximum in the order the claims are received and processed by the 
Plan. Therefore, you have been asked to pay a $30 copayment for the office visit. The office visit falls within 
the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayment for a specialist office visit provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this specific testing is not covered per 
Medicare rules. 
 
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 the laboratory services provided on 
January 6, 2022, have been met. Specifically, no medical records were provided from the enrollees ordering provider to indicate why the testing was ordered. Without these medical records, the medical necessity and 
reasonableness of the testing cannot be determined. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on January 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 8MG Tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 medication have not been met. Drugs like ondansetron are only covered under the medical benefit if it being used as an oral anti-nausea drug that is given with chemotherapy 
and used as a full replacement for intravenous anti-nausea treatment and administered for a period not 
exceeding 48 hours from the start of chemotherapy. Otherwise, it is usually filled by the pharmacy benefit. The 
information shows it is not being used as a full replacement for intravenous anti-nausea treatment. Therefore, 
the drug is covered under the pharmacy benefit. Therefore, we decided that the Plan does not have to pre-
approve Ondansetron 8MG Tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Daily skilled services 
are not required. You are walking short household distances with a rolling walker with supervision to contact 
guard assistance and is supervision to contact guard assist for transfers. Provided records do not document a 
significant decline in your functional status to necessitate daily inpatient skilled therapy services. You do not 
require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document 
that services in the home or an assisted living facility with home health care or in a long-term care facility on a 
part time basis are not appropriate in this case. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray of the abdomen coded 74022 provided on January 
30, 2022. 
 
You asked the Plan to pay for the X-ray of the abdomen. You say that you would like this claim reprocessed. 
The Plan denied your request. The Plan says a modifier was not billed to this claim to represent the services as 
separate or distinct. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 74022. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the X-ray of the abdomen coded 74022 provided on January 30, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation services (A0428, 
A0425) provided on October 26, 2021. 
 
You asked the Plan to pay for the services. You say that this was a non-emergent hospital discharge transport 
and should be a covered service. The Plan denied your request. The Plan says this was a non-emergent hospital 
discharge transport and should be a covered service. 
 
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 the 
record states that the patient could not be transported by wheelchair due to lack of truncal support. The patient 
was noted to be sitting in bed when the transport began. Even if sitting in a wheelchair for the duration of 
transport was not possible, transportation by stretcher van would have been medically reasonable and was not 
contraindicated. The documentation does not support that the patient needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on 
10/26/21. The patient was alert with stable vital signs and was being discharged from acute care to a living 
facility. There was no need for BLS or ALS monitoring or intervention during transport. The documentation 
does not support that the ambulance transport on 10/26/21 was medically reasonable and necessary for the 
patient. 
 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 non-emergent ambulance transportation services (A0428, A0425) provided on October 26, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for X-ray of the chest (71046) provided on August 16, 2021. 
 
You asked the Plan to pay for X-ray of the chest. You say that you would like this claim reprocessed based on 
the medical documentation. The Plan denied your request. The Plan says this is a duplicate claim to a claim that 
is already 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 71046 is radiologic examination, chest; 2 views. 
 
We looked at the file and Medicare rules. In this case, the documentation does not support an additional X-ray 
was performed beyond what was paid already by the Plan. Based on this information, we decided that Medicare rules for coverage of X-ray of the chest have not been met. Therefore, we decided that the Plan does not have 
to pay for X-ray of the chest (71046) provided on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 29, 
2021. 
 
You asked the Plan to pay for the services. You say that supporting documentation was attached. The Plan 
denied your request. The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 60200: 
 
Excision of cyst or adenoma of thyroid, or transection of isthmus 
 
CPT 99232: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: An expanded problem focused interval history; An expanded problem focused 
examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to 
therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the 
patient's hospital floor or unit 
 
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 that the operative report describes 
excision of isthmus, in addition to tracheotomy. In this case, there is a more appropriate code to report for 
service performed. CPT code 60200 should be billed as a standalone procedure for excision of cyst or adenoma 
of thyroid, or transection of isthmus, when performed in the absence of tracheostomy. In terms of CPT 99232, 
the services provided are within a global period. Therefore, this procedure would not be reported separately. 
 
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 surgical services provided to the enrollee on November 29, 2021.