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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on November 19, 2021. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  Our physician reviewer found two separate transports occurred on November 19, 2021 from the enrollee's 
residence to the acute care hospital. It is unclear which transport(s) is/are being disputed in this case. It is also 
unclear why the transport(s) is/are being denied, but the provider reports that one claim was denied as a 
duplicate. The first transport was not medically necessary. The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport.  
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. The second transport is not fully documented and therefore not 
supported. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6196, A6402, A6257, A6219, A4357, 
A4310, A4358) provided on January 27, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery. The physician order and delivery 
documentation is not itemized. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for wound care 
supplies (A6196, A6402, A6257, A6219, A4357, A4310, A4358) provided on January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided from April 9, 2022, to 
April 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital care. You say that the provider is not responsible for 
obtaining authorization. The Plan denied your request. The Plan says services from non-contracted providers 
are not covered unless preauthorized. 
 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 subsequent hospital care provided from April 9, 
2022, to April 14, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for omental flap, intra-abdominal (List separately in addition to 
code for primary procedure) provided to the enrollee on April 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 49905 is "Omental flap, intra-abdominal (List separately 
in addition to code for primary procedure)." 
 
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 when the omental flap is 
repositioned to repair a defect intra-abdominally, it is considered a secondary procedure in the setting of 
multiple abominal procedures including pyloroplasty. In this case, it was merely utilized as a patch to help 
reinforce the pyloroplasty. It cannot be billed as a separate primary procedure.  A secondary modifier should be utilized, as it represents a minor procedure to support the pyloroplasty. 
 
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 omental flap, intra-abdominal (List separately in addition to code for primary procedure) 
provided to the enrollee on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance used with a therapeutic continuous 
glucose monitor (CGM) device (K0553) provided November 9, 2022. 
 
You asked the Plan to pay for the Freestyle 2 Sensor Kit. You say that please consider this claim for payment. 
The Plan denied your request. The Plan says the records do not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the medical records included the proof of delivery, 
however, the date of service of November 9, 2022 does not match the delivery/shipping date or the date the 
label was created. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supply allowance used with a 
therapeutic continuous glucose monitor (CGM) device (K0553) provided November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says when 
ready to leave the hospital, the enrollee may safely receive this care in another setting, such as an Inpatient 
Rehabilitation Facility (IRF), a Skilled Nursing Facility (SNF) or at home with home health services. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where currently receiving care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support the 
medical necessity of these lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary, and the best course of 
action for the well-being of the patient and their health. The Plan denied your request. The Plan says there has 
not been any initial treatment with the device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not document the clinical response to an initial treatment with this device. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0651, E0667).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for hospital services provided from April 11, 2022 to April 20, 2022. 
 
You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that you may resubmit the claim under Part B. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for hospital services provided from 
April 11, 2022 to April 20, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 1, 2021 to August 6, 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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 documentation from July 17, 
2021, to July 23, 2021 repeatedly contradicts itself. Additionally, there is no documentation from August 1, 
2021, to August 6, 2021. There is no clear evidence of a open lesion or surgical wound. There is no evidence, 
from orders or care notes, that the enrollee received any care for an open lesion or a surgical wound. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from August 1, 2021 to August 
6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70486 provided on July 31, 2022. 
 
You asked the Plan to pay for procedure code 70486. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is not separately payable. 
 
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 70486 is not supported in the medical record. Specifically, per Addendum B - OPPS 
Payment by HCPCS Code for CY 2022, this code has a status of Q3 and was billed on the same day as code 
99284 which has a status indicator of V. Based on this information, we decided that Medicare rules for 
coverage of procedure code 70486 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 70486 provided on July 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that you would like the requested services 
approved. The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal cap for bridge (D6751) for teeth 
19 and 21, and a false tooth for bridge (D6241) for tooth 20. 
 
You asked the Plan to pre-approve white glass with metal cap for bridge for teeth 19 and 21, and a false tooth 
for bridge for tooth 20. You say that these services are required. The Plan denied your request. The Plan says 
the requested services are not medically necessary. 
 
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. The Plan covers white glass 
with metal cap for bridge for teeth 19 and 21, and a false tooth for bridge for tooth 20 when the services are 
medically necessary and reasonable.  
 
   
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 white glass with metal cap for bridge 
for teeth 19 and 21, and a false tooth for bridge for tooth 20. Our reviewer says that Plan criteria is not met for 
coverage. Our physician reviewer found there are several missing posterior teeth and no missing anterior 
teeth. According to the Plan criteria, bridges are only allowable in limited circumstances and involving only 
anterior teeth where there are no missing posterior teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of white glass with metal cap for bridge for teeth 19 and 21, and a false tooth for 
bridge for tooth 20 have not been met. Therefore, we decided that the Plan does not have to pre-approve white 
glass with metal cap for bridge (D6751) for teeth 19 and 21, and a false tooth for bridge (D6241) for tooth 20.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services (99285) provided on June 27, 2022. 
 
You asked the Plan to pay for an additional unit of code 99285. The Plan denied your request. The Plan says 
only one unit of code 99285 is 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 an additional unit of CPT code 99285 is not supported in the medical record. Specifically, the 
records show that only one emergency department visit was provided on the date of service in question. Based 
on this information, we decided that Medicare rules for coverage of an additional unit of code 99285 have not 
been met. Therefore, we decided that the Plan does not have to pay for the emergency services (99285) 
provided on June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox, 600 units per session. 
 
You asked the Plan to pre-approve Botox. You say that in order to improve the enrollee's condition and way of 
life, you recommend they receive 600 units of Botox every 90 days. You also say that this will help both 
extremities to be in sync. The Plan denied your request. The Plan says Botox at the requested doses is 
unproven. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the use 
of 600 units of Botox every 84 days for treatment of spasticity is not indicated, supported or recommended in 
any of the compendia. Our physician reviewer found the requested use of Botox, 600 units per session every 84 
days is not Food and Drug Administration-approved for the enrollee's diagnosis. As stated in the Medicare-
approved major drug compendia: The maximum cumulative Botox dosage should not exceed 400 units in a 3-
month interval when treating adult patients for spasticity. Our reviewer also found that the use of 600 units of 
Botox every 84 days for treatment of spasticity is not supported by one of the major drug compendia or by 
clinical research that appears in a Centers for Medicare and Medicaid Services (CMS) approved medical 
journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox, 600 units per session.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a therapeutic continuous glucose monitor (CGM) supply allowance 
provided on October 28, 2021. 
 
You asked the Plan to pay for CGM supply allowance. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the Plan did not receive the needed supporting records. 
 
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 denied payment because supporting records were not submitted. 
However, you submitted supporting records including a standard written order fulfilling all criteria which was 
communicated to you prior to dispensing the supplies and valid proof of delivery. The Plan did not indicate 
why the supporting records submitted were not acceptable, nor did the Plan provide any other evidence or 
rationale to support a denial. Therefore, the Plan has not shown that their decision to deny payment for this 
claim is correct or justified. Therefore, we decided that the Plan has to pay for a therapeutic continuous glucose 
monitor (CGM) supply allowance provided on October 28, 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.