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

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
low level of medical decision making (99213) provided August 25, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee cannot afford the cost of this service. 
The Plan denied your request. The Plan says this service is not covered because it was provided OON without a 
referral. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers services from an ophthalmologist when the enrollee first obtains a referral from their 
primary care provider. 
 
We looked at the file and the Plan's rules. In this case the services were provided by an OON ophthalmologist 
without referral from the enrollees primary care provider. Based on this information, we decided that the 
Plan's rules for coverage of the office visit with an ophthalmologist have not been met. Therefore, we decided 
that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of 
an established patient, which requires a medically appropriate history and/or examination and low level of 
medical decision making (99213) provided August 25, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and was treated for pain. You were at a standby assist to contact guard assist level for functional mobility 
including gait to 100 feet x 2 with a rolling walker. You do not require skilled nursing or therapy services on a 
daily basis. You do 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service June 28, 
2021. 
 
You asked the Plan to pay for procedure code 99232. You say that you have submitted enough medical records 
to substantiate the service performed. The Plan denied your request. The Plan says it has paid for the other 
dates of service you have billed, but you have not provided medical records for the June 28, 2021, date of 
service. The Plan has requested records from this date of service from you multiple times. 
 
The Plan must follow Medicare rules. Medicare rules say that medical record documentation supports the level 
of service reported. In this case, you have not provided any medical records showing services provided on date 
of service June 28, 2021. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99232 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99232 billed for date of service June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a myoelectric orthotic device for the upper extremity (L8702) and 
related services. 
 
You asked the Plan to pre-approve a myoelectric orthotic device. You say that the requested orthotic device is 
medically necessary.  The Plan denied your request. The Plan says that the requested orthotic device does not 
meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a myoelectric orthotic device. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has suffered several CVAs with spastic left hemiplegia of the arm. 
She has been using a myoelectric orthotic device for the past 12 months. The enrollee has not had any 
complications associated with the device. The enrollee meets all of the criteria for the 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 a myoelectric orthotic device have been met. Therefore, we decided that the 
Plan has to pre-approve a myoelectric orthotic device for the upper extremity (L8702) and related services.  
 
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 lab services (82274, 82656, 83631, 83520) provided January 
13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 (82274, 82656, 83631, 83520) provided January 13, 2021.
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 does not meet 
criteria. 
 
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While you may benefit 
from physical therapy, and occupational therapy, your rehab can be safely provided at a lower intensity and 
alternate setting such as in a skilled nursing facility with therapy as tolerated. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 1, 
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 20931 is not supported by the medical records submitted. 
 
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 20931 is "Allograft, structural, for spine surgery only 
(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 the operative note describes the use of 
an expandable interbody. It does not describe structural allograft. There was no rigid bone described in the 
operative note as a spacer. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 30, 
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 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 the denied codes is: 
 
CPT 15004: 
 
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including 
subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, 
genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 
 
 CPT 15733: 
 
Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, 
genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) 
 
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 the medical records. Our reviewer found the records do not support that CPT 
15004 and 15733 were rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 30, 
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 G0483 remains not supported. 
 
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 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 drug testing services provided to the enrollee on March 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 27, 
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 did not bill according to Medicare 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, we have confirmed that code 76942 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on August 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy services provided to the enrollee on December 
17, 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 code is not supported by the records submitted. 
 
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 45380 is "Colonoscopy, flexible; with biopsy, single or 
multiple." 
 
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 the review has determined that the 
records did not support the coding of CPT 45380. The records do not support that a flexible colonoscopy with 
biopsy was rendered in this case. The requested service code is not substantiated by the clinical documentation 
submitted for review.  
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 colonoscopy services provided to the enrollee on December 17, 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 the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested SNF services do not meet the requirements for approval. 
 
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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has stabilized medically, and has been receiving skilled rehab services in an inpatient rehabilitation facility 
(IRF). The enrollee has tolerated inpatient rehab services and continues to improve with daily skilled nursing 
and/or skilled therapy services.  He could benefit from continued services at the current level of care. He has 
made slow progress with therapy, and there is no indication that transfer to a skilled nursing facility would be 
required. He can continue to receive skilled rehab services at the current IRF or be stepped down to a lower 
level of care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab 
facility.  Admission to a SNF for inpatient skilled rehab services is 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 admission 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36215) and angiography 
(75710) provided on October 18, 2021. 
 
You asked the Plan to pay for the selective catheter placement (36215) and angiography (75710). You say that 
the documentation substantiates that both services are separately billable with the combination of codes billed. 
You say that the medical rationale is substantiated, and the documentation supports submission of payment. 
The Plan denied your request. The Plan says procedure codes 36215 and 75710 are not supported in the 
medical records submitted. 
 
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 36215 is selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family. The CPT Code Manual definition 
of code 75710 is angiography, extremity, unilateral, radiological supervision and interpretation. 
 
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 selective catheter placement (36215) and angiography 
(75710). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that the operative report does not include documentation to support selective 
catheter placement was performed for suspected inflow problem. Since CPT 36215 is not supported by the 
documentation, CPT 75710 is also not supported. 
 
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 selective catheter placement (36215) and angiography (75710) have not 
been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36215) 
and angiography (75710) provided on October 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care telehealth consultation (G0509) provided on 
May 16, 2021. 
 
You asked the Plan to pay for the telehealth consult. You say that the services should be covered. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 7, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the critical care telehealth 
consultation (G0509) provided on May 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased on June 25, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you believe that you should be reimbursed for the 
hearing aids you purchased. The Plan denied your request. The Plan says hearing aids are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids you 
purchased on June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. You say 
that the enrollee has been on Aranesp as needed monthly since at least 2019. You say that the enrollee's 
hemoglobin has been stable due to Aranesp. The Plan denied your request. The Plan says the use of the 
requested drug is not reasonable and necessary because there is no recent documented transferrin saturation of 
at least 20% or ferritin of at least 100 ng/mL. The Plan says that the labs submitted were not timely having 
been from blood work drawn in May of 2021. The Plan says that the documentation presented does not confirm 
that the enrollee satisfies the criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aranesp. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the diagnosis of anemia of chronic 
kidney disease is not in question. It is mandatory for iron stores (ferritin and/or iron saturation), while on 
therapy and iron, to be low before therapy con be continued. The records show that the enrollee's have not been 
checked since May of 2021. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.