Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the E-STIM device provided on June 8, 2022. 
 
You asked the Plan to pay for the E-STIM device. You say that this item was billed correctly and should be 
covered. The Plan denied your request. The Plan says there is evidence of misrepresented services. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the only medical records you provided are dated June 10, 2022, which is AFTER the 
date that this item was supposedly ordered and delivered.  You have supplied no medical records to indicate 
that the patient's physician saw the patient prior to you sending them this device. Therefore, we decided that the 
Plan does not have to pay for the E-STIM device provided on June 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for admission to a SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 records provided support the need for IRF care. 
You say that you need emergency therapy and to be closer to home. The Plan denied your request. The Plan 
says the guidelines for coverage have not been met. The Plan says that the enrollee is now medically stable and 
is progressing well with therapies. The Plan says that the enrollee's needs can be met at a lower level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for stroke. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 21, 
2020. 
 
You asked the Plan to pay for the coronavirus test. You say that this should be reprocessed and paid based on 
the current federal guidelines for coronavirus testing and reimbursement. The Plan denied your request. The 
Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The 
Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visits (90834, 90837) provided from 
January 17, 2022, to June 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that these services should be reprocessed 
and paid. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 the psychotherapy visits (90834, 90837) provided from January 
17, 2022, to June 27, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37252 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 37252. You say that there is no procedure to procedure edit for 
these codes so no modifier should be required for code 37252. The Plan denied your request. The Plan says this 
code was not billed with an appropriate primary code. 
 
The Plan must follow Medicare rules. Medicare rules say that a Type I add-on code has a specified list of 
primary codes with which it can be reported. 
 
 We looked at the file and Medicare rules. Procedure code 37252 is a Type I add-on code. Per review of the 
add-on code edits, code 37183, the primary code billed, is not listed as eligible for use with 37252. Based on 
this information, we decided that Medicare rules for coverage of procedure code 37252 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 37252 billed for date of service 
June 23, 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. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the records do not support the need to transfer to an 
LTACH facility. 
 
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 she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the current 
acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided April 26, 2022, to May 
24, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules say that certain data elements are required on the claim and the 
NOA. 
 
Review of the file shows that the admission date on the NOA is entered correctly as January 25, 2022. This 
admission date should be entered on all subsequent final claims until the member is discharged. As the claim 
was submitted with incorrect information, no payment can be made on this claim. Therefore, we decided that 
the Plan does not have to pay for the home health services provided April 26, 2022, to May 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on July 2, 
2022. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $200 
copayment for ambulance services.  
 
You have been asked to pay $200 copayment for ambulance service. This item/service falls within the 
ambulance services 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 ambulance service 
provided on July 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 31, 2021 to August 
29, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not submitted with a valid "through" date. The "through" date must be 29 days after 
the From date. Therefore, we decided that the Plan does not have to pay for home health services provided on 
July 31, 2021 to August 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 13, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the criteria for coverage 
have not been met as required documentation is missing. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records provided are from over two years before the equipment was provided. There is no updated documentation closer to the service date in question. Without recent medical 
records, the criteria for coverage cannot be examined.  Therefore, we decided that the Plan does not have to pay 
for the electrical stimulator supplies provided on June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that she is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied.  
 
 
 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care such as at home or in a skilled nursing facility or other 
appropriate longer term care facility. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88381, 88360 and 88342 billed for 
date of service March 3, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88381, 88360 and 88342. You say that you billed with 
the correct Place of Service code. The Plan denied your request. The Plan says these codes are included in the 
facility payment and is not separately payable. You did not bill with the required 26 modifier.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88381, 88360 
and 88342. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88381, 88360 and 88342. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88341, 88381, 88360 and 88342 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88381, 88360 and 88342 billed for date of service March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a duplex scan of lower extremity 
arteries or arterial bypass grafts provided on June 21, 2022. 
 
You asked the Plan to pay for physician's services for a duplex scan of lower extremity arteries or arterial 
bypass grafts. You say that the service was rendered in an appropriate place of service. The Plan denied your 
request. The Plan says based on member's claims history, the claim was billed with an inappropriate place of 
service 22 (outpatient). The patient was inpatient during this date of service per referring claim number 
820221860415025 for dates of service June 20, 2022, to June 30, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
place of service (POS) code to be used by the physician or other supplier will be assigned as the same setting in 
which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered 
hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be 
reported regardless of where the face-to-face service takes place. We looked at the file and Medicare rules. Medicare says for all services (with two (2) exceptions), the place of 
service (POS) code to be used by the physician or other supplier will be assigned as the same setting in which 
the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered 
hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be 
reported regardless of where the face-to-face service takes place. Based on this information, we decided that 
Medicare rules for coverage of physician's services for a duplex scan of lower extremity arteries or arterial 
bypass grafts have not been met. Therefore, we decided that the Plan does not have to pay for physician's 
services for a duplex scan of lower extremity arteries or arterial bypass grafts provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging 
guidance (ie, fluoroscopy or CT) (CPT code 62321). 
 
You asked the Plan to pre-approve the injection. You say that you had this done a year ago. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
follows Medicare 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 pre-approve the injection. 
Our physician reviewer found there is no advanced imaging of the cervical spine. The degree and duration of 
the last cervical epidural steroid injection are not clearly documented. There is no documentation of advanced 
imaging showing evidence of central disc herniation, osteophytes, or severe degenerative disc disease causing 
foraminal or central spinal stenosis; at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using SAME scale for at least three months. Therefore, the request is 
deemed not medically reasonable and necessary. 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 injection(s), of diagnostic or therapeutic 
substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with 
imaging guidance (ie, fluoroscopy or CT) (CPT code 62321).