Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on May 25,
2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status
indicator of "B." This means that payment for this code is always bundled into payment for other services not
specified and no separate payment can be made. Based on this information, we decided that Medicare rules for
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay
for the anesthesia services coded 99100 provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 12, 201.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that
NP/PA may perform physical therapy services under State law.
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide
physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.
Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. 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 services provided on May 12, 201.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87532, 87541, 87581, and 87640 provided on November 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87486, 87496, 87498, 87532, 87541, 87581, and 87640 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an Assisted Living Facility place of service 13.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87532, 87541, 87581, and 87640 provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 1, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the 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.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. 
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 1, 2020.
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 the requested ventilator. The Plan denied your request. The Plan says the 
requested ventilator setting 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 the requested ventilator. Our physician 
reviewer found that a home ventilator is not medically necessary. You have severe COPD with chronic hypoxic 
and hypercarbic respiratory failure. You may benefit from BiPAP support at night. However, Medicare does 
not cover a home ventilator when used as BiPAP. Therefore, the request is 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 requested 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 an additional billed unit of injection services coded as 64494 
provided on March 18, 2021. 
 
You asked the Plan to pay for an additional billed unit of injection services. You say that you would like this 
claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim has denied 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of an 
additional billed unit of injection services have not been met. Therefore, we decided that the Plan does not have 
to pay for an additional billed unit of injection services coded as 64494 provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on February 3, 
2021 to April 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
for medical necessity. The Plan denied your request. The Plan says telehealth services rendered by an OON 
provider will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan does not have to pay for telehealth services rendered by an OON provider. 
 
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 the psychotherapy services (90837) provided on 
February 3, 2021 to April 28, 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) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no 
daily skilled nursing or therapy needs. 
 
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 services. Our physician reviewer 
found that the enrollee was admitted to an acute care hospital with rhabdomyolysis and dehydration. She has 
been treated medically and stabilized. The most recent therapy documentation indicates she is able to ambulate 
up to 120 feet with contact guard assistance and is able to accomplish most self-care tasks with supervision or 
minimal assistance. She does not have any complex daily wound care, parental medications or required care for 
a feeding tube. She does not require skilled nursing and/or skilled therapy services on a daily basis. Admission 
to a SNF for 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder detect test identified with code 0012M 
provided on April 15, 2021. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder identified with code 0012M is non-
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cxbladder detect test have not been met. Therefore, we decided that the Plan does not have to 
pay for the Cxbladder detect test identified with code 0012M provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 5, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in 
the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (36000) provided on March 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Code 36000 is assigned a status indicator of "B" under the Physician 
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for 
other services. No separate payment can be made for this service. 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 services (36000) provided on March 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis you had on June 21, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you don't think you should have to 
pay this copayment because the results of your first CT scan were not clear. As a result, you had to have a 
second copayment, so you shouldn't have to pay a second copayment. The Plan denied your request. The Plan 
says you were charged this copayment 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 a $250 
copayment per day for diagnostic radiology services.  
 
 
You have been asked to pay a $250 copayment per day for the CT scan. The CT scan falls within the diagnostic 
radiology services benefit category. This copayment applies regardless of the reason for the service. 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 computed tomography (CT) scan of the abdomen and 
pelvis you had on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on August 20, 2020. 
 
You asked the Plan to pay for the services provided. You say that the treatment was medically necessary and 
appropriate. The Plan denied your request. The Plan says the clinical effectiveness of the services has not been 
demonstrated in peer reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that an electrical cell stimulation, vasopneumatic device therapy, and nutri-pharmaceutical 
blend injection were provided. 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 services 
provided. Our physician reviewer found that the enrollee has bilateral shoulder pain. The physical exam does 
not document a decrease in range of motion. The progress note refers to pain on range of motion. The services 
provided are not evidence-based therapy, and the effectiveness and duration of effect are uncertain.  Therefore, 
the request was not medically reasonable or 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 services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the pain management services provided on August 20, 2020.
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 an IRF is the best option for your ongoing needs. 
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your care needs 
can be met in an alternate setting. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional three levels of radiofrequency ablation 
 
You asked the Plan to pre-approve the additional levels. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request for the additional treatment of three levels bilaterally appears to 
be an error in submission. 
 
The Plan must follow Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, 
are allowed per session per spine region. 
 
The request appears to be simply for a procedure at L3-4, L4-5, L5-S1. There is no evidence of need for the 
additional three levels. It appears that it was a mistake to request the additional three levels. Based on this 
information, we decided that Medicare rules for coverage of the additional levels have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an additional three levels of radiofrequency ablation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit (99203) provided to you on June 
9, 2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit (99203) provided to you on June 9, 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 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: 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital. After review of the medical records, it is not clear if the enrollee requires 
daily skilled nursing. The enrollee does not require daily skilled therapy services. The enrollee is medically 
stable and can receive further rehab services at a lower level of care. Although further rehabilitation services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a SNF. There is no clear order for parental medications or daily complex 
wound care. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The 
enrollee's physical function is at or near their baseline and they can receive services at a lower level of c are. 
Admission to a SNF for inpatient skilled rehabilitation 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection and ultrasonic guidance provided on July 29, 
2019 by a non-network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without prior authorization. 
 
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 the injection and ultrasonic guidance provided on 
July 29, 2019 by a non-network provider.