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

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1930) and addition to lower 
extremity orthosis (L2820) provided March 29, 2022. 
 
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says 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 a valid proof of delivery, or a delivery ticket to indicate the specific supplies 
provided in this case. 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 ankle foot 
orthosis (L1930) and addition to lower extremity orthosis (L2820) provided March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fourth day of your inpatient hospital 
stay provided from March 15, 2022, to March 19, 2022. 
 
You asked the Plan to waive the copayment for the fourth day of your inpatient hospital stay. You say that you 
shouldn't be charged for the fourth day since it was not your fault you had to stay but a problem the hospital 
had. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $195 
copayment for each Medicare covered day, for days 1 through 10, $0 copayment for each additional day.  
 
 
 
 You have been asked to pay $780 ($195 x 4 days) copayment for your inpatient hospital stay. 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 the fourth day of your inpatient hospital stay provided from March 15, 2022, to March 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in 
the home health or hospice setting (G0151). 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
medical necessity is not established for additional physical therapy services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 physical therapy services. Our 
reviewer says that the physical therapy services are not reasonable and necessary. Our physician reviewer 
found you have previously been treated with outpatient and home therapies, and should be independent with a 
home exercise program. There is no documentation of a recurrent injury or further decline in function. Our 
reviewer also found that the additional therapy services are not an appropriate duration and frequency for 
treatment of your medical condition and therefore are not medically 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve services performed by a qualified physical therapist in the home health or 
hospice setting (G0151).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on November 26, 2021. 
 
You asked the Plan to pay for telehealth services. The Plan denied your request. The Plan says the members 
Plan does not have out-of-network benefits for telehealth/virtual visits. 
 
The Plan contract does not cover virtual care/telehealth services out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care/telehealth 
services out-of-network. Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on November 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 the drug testing services provided on February 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric peroral endoscopic myotomy (G-POEM). 
 
You asked the Plan to pre-approve the G-POEM. You say that the enrollee needs this service. The Plan denied 
your request. The Plan says the requested service is 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 pre-approve the G-POEM. Our reviewer says that 
the requested gastric peroral endoscopic myotomy (G-POEM) is not considered medically reasonable and 
necessary in this case. Our physician reviewer found G-POEM is still a novel technique that while promising is 
not standard-of-care. The reviewer found that the request for G-POEM may not, at this time, represent the 
enrollee's best or safest option. The reviewer found that the provided documentation does not support that G-
POEM, given the enrollee's multiple comorbidities and surgically altered anatomy, is 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 G-POEM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gastric peroral endoscopic myotomy (G-POEM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053 84443, 85025) provided on January 10, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services were billed appropriately 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 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 (80053 84443, 85025) provided on January 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) physical therapy 
(PT) services provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for the OON PT services. You say that you cannot afford the 
copayment. 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 $40 
copayment for each out-of-network therapy visit.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay $30, which is less than the $40 copayment for the OON PT services. The OON PT services fall within the 
Outpatient Rehabilitation 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 
out-of-network (OON) physical therapy (PT) services provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests are included in the dialysis rate. Please reprocess the claim 
for payment as soon as possible. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) procedure of the 
sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that RFA of the SI joint is medically 
necessary. The Plan denied your request. The Plan says RFA of the SI joint is experimental/investigational. 
 
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 RFA of the SI joint. Our reviewer says 
that RFA of the SI joint is not considered medically reasonable and necessary. Our physician reviewer found 
that RFA of the SI joint is considered experimental because of the wide variation in efficacy in the literature.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve RFA of the SI joint.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from February 18, 2022, to February 23, 
2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee had been given 
inpatient admission services that clearly meet medical necessity. The Plan denied your request. The Plan says 
that the record does not show that the enrollee did not get better within 48 hours and still was unable to drink, 
had blocked intestines, could not keep their blood pressure in the normal range, had problems with their 
kidneys working, or had other medical problems that needed to be treated in a hospital. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record shows that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the inpatient stay provided from February 18, 2022, to February 23, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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. Medical records were requested and never received from the health plan. 
Without this information, the plan's denial is not able to be substantiated. Therefore, we decided that the Plan 
has to pre-approve a home ventilator.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the emergency ambulance transport (A0427), and 
ground mileage (A0425) provided on March 15, 2022. 
 
You asked the Plan to reimburse you for the ambulance services. You say that you received invoice in the 
amount of $734.10. You say that you should not be responsible for this amount. The Plan denied your request. 
The Plan says reimbursement will not be paid in the amount of $240 as no payment was made by the enrollee. 
 
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 $240 
copayment for Ambulance Services.  
 
You have been asked to pay a $240 copayment for the ambulance services. The ambulance services fall 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 reimburse you for the emergency 
ambulance transport (A0427), and ground mileage (A0425) provided on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of code 0089U-XS billed for date of service 
January 25, 2022. 
 
You asked the Plan to pay for the second unit of 0089U-XS. You say that this service was medically necessary. 
The Plan denied your request. The Plan says it has paid for codes 0089U and one unit of code 0089U-XS. 
However, the Plan contends that the second unit of 0089U-XS is not supported in the medical record. 
 
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 0089U-XS is Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, 
superficial collection using adhesive patch(es).  The XS modifier is defined as: Separate Structure, a service 
that is distinct because it was performed on a separate organ/ structure. 
 
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 second unit of 0089U-XS. Our reviewer says that this 
code is supported. Our reviewer found the medical records show that there were two separate units of code 
0089U-XS provided on this date of service. 
 
 
 
 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 second unit of 0089U-XS have been met. Therefore, we decided that the 
Plan does not have to pay for a second unit of code 0089U-XS billed for date of service January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 
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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee needs a ventilator to function in life. 
The Plan denied your request. The Plan says a setting that could be delivered by BiPAP is not covered. 
 
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 a ventilator. Our physician reviewer 
found that the record indicates the enrollee was admitted with dyspnea and hypercapnia in the setting of 
chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee 
improved while an inpatient with BiPAP treatment. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. The plan has indicated that coverage for such 
a device is available for consideration upon request.  The elements of the coverage criteria 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 01638, 64416 and 76942 billed on March 
28, 2022. 
 
You asked the Plan to pay for procedure codes 01638, 64416 and 76942. You say that the attached records 
should be reviewed to reprocess the claim for payment. The Plan denied your request. The Plan says this claim 
was billed as inpatient and must be rebilled as outpatient to match the facility claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule, the Place of service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face-to-face service. 
 
  In this case, the CPT Code Manual definition of code 01638 is anesthesia for open or surgical arthroscopic 
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total 
shoulder replacement. The CPT Code Manual definition of code 64416 is injection(s), anesthetic agent(s) 
and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement). The CPT Code 
Manual definition of code 76942 is ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, 
localization device), imaging supervision and interpretation. 
 
We find that procedure codes 01638, 64416 and 76942 are not supported in the medical record. Specifically, 
the claim was billed with the inpatient POS code, but the enrollee was outpatient at the time of service. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 01638, 64416 and 76942 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 01638, 64416 
and 76942 billed on March 28, 2022.