Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
November 24, 2021, to November 25, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you went to the 
emergency room (ER). You also say you were never moved to a room, and you were kept in the ER for almost 
24 hours. 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 $325 
copayment for each inpatient hospital stay. 
 
The records show you were admitted as an inpatient from November 24, 2021, to November 25, 2021. You 
have been asked to pay a $325 copayment for an inpatient hospital stay.  An inpatient hospital stay falls within the Inpatient Hospital Care 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 an inpatient hospital stay provided from November 24, 2021, to November 25, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitor feature coded A9279 provided from August 27, 
2020, through September 25, 2020. 
 
You asked the Plan to pay for the monitor feature. You say that you would like this claim reprocessed based on 
the medical documentation. The Plan denied your request. The Plan says the claim has not been billed as 
required by Medicare coding regulations. 
 
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 A9279 is monitoring feature/device, stand-alone or 
integrated, any type, includes all accessories, components and electronics, not otherwise classified. 
 
We looked at the file and Medicare rules. In this case, A9279 has a Status Code of I under the Physician Fee 
Schedule. This Status Code indicates that the code is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the monitor feature have not been met. Therefore, we decided that the Plan does not have to pay for the monitor feature coded A9279 provided from August 27, 
2020, through September 25, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided by an out-of-network physician on October 16, 
2020. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was in a nursing home and could not 
choose a network provider. The Plan denied your request. The Plan says that no prior authorization was 
obtained. 
 
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 did not submit the 2020 Evidence of Coverage. This means we cannot 
determine if the Plan's denial of non-emergent services is supported. Therefore, we decided that the Plan has to 
pay for the office visit provided by an out-of-network physician on October 16, 2020. 
  
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 laboratory services provided on April 13, 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 covered 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. National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 84481 and 84480. This PTP edit has a modifier indicator of 
0, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with 
this PTP code edit. CPT code(s): 86141, 85651, 86003, 82607, 83090, 86431, 83550, 83970, 84439, 84443, 
84481, 84550, 85025, 80053, 80061, 81000, 82306, 82728, 82746, 83036, 83540, remain not supported. The 
place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an Office setting POS 11; therefore, the billed code cannot be verified. It is noted multiple attempts were 
made to obtain additional information from the provider. 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 laboratory services 
provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic agent injection (64445) provided on July 19, 
2021. 
 
You asked the Plan to pay for the anesthetic agent injection (64445). You say that CPT code 64445 was billed 
with modifier 59 to indicate a separate service. You say that the medical records deem the service medically 
necessary, and payment should be reconsidered. The Plan denied your request. The Plan says the medical 
records received do not support that the procedure or service was distinct or independent from other services 
performed. The Plan also says there is a more appropriate code to be billed for this service provided. 
 
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 64445 is injection(s), anesthetic agent(s) and/or steroid; 
sciatic nerve. 
 
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 anesthetic agent injection (64445). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the anesthesia report documents an injection given, however it does not include specific documentation to 
confirm this procedure is for post op pain management and not for primary anesthesia services. 
 
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 anesthetic agent injection (64445) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthetic agent injection (64445) provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuropathy treatment provided on October 28, 2021. 
 
You asked the Plan to pay for neuropathy treatment. You say that you have gotten back all feeling in your 
hands and legs with the treatments they use. You say that this is important preventive treatment of future 
possible falls and injuries. The Plan denied your request. The Plan says neuropathy treatments are considered 
investigational, unproven or experimental and 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 pay for neuropathy treatment. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the services you underwent were elective in nature. The services provided are not well 
supported within current medical literature for use in the management of neuropathy and neuropathic pain. 
Therefore, the services would not meet the Medicare definition of medical necessity at the time they were 
provided.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropathy treatment have not been met. Therefore, we decided that the Plan 
does not have to pay for neuropathy treatment provided on October 28, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for podiatry services (procedure code 15738) provided to the enrollee on 
September 24, 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 that the operative report did not include documentation of a lower extremity muscle, 
myocutaneous, or fasciocutaneous flap; therefore this code cannot be verified. 
 
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 15738 is "Muscle, myocutaneous, or fasciocutaneous flap; lower extremity." 
 
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 supported by the medical records. Our reviewer found the medical records do indeed support 
that CPT code 15738  muscle, myocutaneous, or fasciocutaneous flap; lower extremity was rendered in this 
case. The operative note dated 9/24/2021 advises that the surgeon remodeled the skin, excising skin edges to 
create a rotational flap for closure. The surgeon lifted the full thickness including the intrinsic muscles along 
the lateral aspect of the foot including the abductor digiti quinti muscle. This was then rotated and sutured into 
place using 3  0 Vicryl with simple interrupted sutures. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
podiatry services (procedure code 15738) provided to the enrollee on September 24, 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 laboratory services provided to the enrollee on May 24, 
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 denied code remains 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. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 laboratory services provided to the 
enrollee on May 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
August 22, 2021. 
 
  You asked the Plan to pay for the non-covered ambulance mileage. The Plan denied your request. The Plan 
says the GY modifier (A0888) is not billable and is therefore not covered by Medicare or the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare law contains a restriction that miles 
beyond the closest available facility cannot be billed to Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-covered ambulance mileage have not been met. Specifically, code A0888 is not supported 
because it represents non-covered extra miles. Therefore, we decided that the Plan does not have to pay for the 
non-covered ambulance mileage (A0888) provided on August 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 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 the beneficiary is an 82-year-old female with 
stage 4 ovarian cancer. In this case, there are no identifiable skilled nursing service needs and no identifiable 
skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services 
on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria 
for 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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided on August 
27, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 laboratory service have not been met. CPT code 81479 (1 Unit) 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory service (CPT code 81479) provided on August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, any joint of upper extremity; without contrast 
material(s) (CPT code 73221). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says the MRI is not necessary. 
 
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 to pre-approve the MRI. Our physician reviewer found 
the provided documentation did not clearly show that you had fully exhausted conservative treatment, had been 
having shoulder issues for more than three (3) months, or had any signs of a red flag diagnosis which might 
warrant earlier consideration for advanced imaging. Therefore, without sufficient support made for this request, 
the left shoulder MRI will be considered not medically necessary at this time. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI, any 
joint of upper extremity; without contrast material(s) (CPT code 73221).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. 
 The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight in an IRF. While the 
enrollee may benefit from additional multiple therapies, including physical and occupational therapy, the 
documentation does not reveal that the enrollee requires this therapy on an intensive IRF level or can tolerate 
therapy on an intensive level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. This patient does not have chronic obstructive 
pulmonary disease (COPD), neuromuscular disease, or thoracic restrictive disease. There is no documentation 
of chronic respiratory failure with carbon dioxide (CO2) retention. The patient has obstructive sleep apnea 
(OSA) and continuous positive airway pressure (CPAP) did not work, i.e., no CPAP pressure was found that 
alleviated the sleep disordered breathing. Bilevel positive airway pressure (BiPAP) has not been tried. This 
patient should have a BiPAP titration sleep study. The denial of the ventilator is upheld. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 31, 
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 Current Procedural Terminology (CPT) code 81479 (1 Unit) remains 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. 
 
We find that CPT code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical 
record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when 
the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the 
records reflect of place of service of an on campus outpatient hospital. 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 laboratory services provided to the enrollee on August 31, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ferric carboxymaltose, 1MG injection (CPT code 
J1439). 
 You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not had inadequate response or intolerance to two (2) 
preferred agents (Ferrlecit or Infed) and has not been on the non-preferred agent in the past 365 days. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 injection. Our physician reviewer 
found the provided documentation did not clearly show that the enrollee had tried and failed either Ferrlecit or 
Infed for their condition. Neither Ferrlecit nor Infed would be less effective and/or more likely to have adverse 
effects for the enrollee as they are equivalent in safety and effectiveness based on current evidence. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ferric carboxymaltose, 1MG injection (CPT code J1439).