Persius/hicric huggingface dataset:
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 the enrollee needs continued critical and 
recovery care in an LTACH. You say that the enrollee needs further treatment and management for antibiotic 
therapy, physical therapy, occupational therapy, speech therapy, contact isolation, cardiac monitoring, and 
wound care with daily physician oversight. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 enrollee is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
   
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for open treatment of femoral shaft fracture provided to the enrollee on 
June 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 27506-59 RT (1 Unit) remains 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 27506 is "Open treatment of femoral shaft fracture, with or without external fixation, with insertion of 
intramedullary implant, with or without cerclage and/or locking screws." 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
right periprosthetic distal femur fracture. She underwent an open reduction and internal fixation of the right 
periprosthetic distal femur fracture; removal of external fixator right knee; and intramedullary nail fixation of 
the right distal femur fracture on 6/24/22. The procedure details cite that the right femoral shaft fracture was 
repaired with reduction and fixation of the distal femur fracture with the plate and intramedullary nail fixation. 
There does appear to have been two reduction/fixation procedures performed, including plate/screws and IM 
rod. Therefore, the records support CPT 27506 (open treatment of femoral shaft fracture, with or without 
external fixation with insertion of intramedullary implant, with or without cerclage and/or locking screws) as a 
separate and distinct procedure from CPT 27507: open treatment of femoral shaft fracture with plate/screws, 
with or without cerclage. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
open treatment of femoral shaft fracture provided to the enrollee on June 24, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve chiropractic manipulative treatments (98941 x 2) and manual 
therapy techniques (97140 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan based its denial solely on the fact that the supplemental 
benefit was exhausted, which is not supported by the documentation as the spinal manipulation provided 
cannot be counted as a supplemental service since it is covered by Medicare. The Plan did not review for 
medical necessity for the requested two Medicare-covered chiropractic treatments. Additionally, the four 
requested non-Medicare (supplemental) treatments are eligible for coverage due to the annual limitation not 
being exhausted. Therefore, we decided that the Plan has to pre-approve chiropractic manipulative treatments 
(98941 x 2) and manual therapy techniques (97140 x 4).  
 
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 procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service December 15, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you don't 
believe the 26 modifier is required. The Plan denied your request. The Plan says this code is 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, 88342, 88360, 
and 88381. 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, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service December 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 
22, 2022, to April 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the admission date is wrong. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The admit date is in 2021. For enrollees receiving services in 2021 that continue into 2022, the home health 
agency must submit a Notice of Admission (NOA) with a one-time artificial "admission" date corresponding 
the "from" date of the first period of continuing care in 2022. 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 home health services provided to the enrollee from March 22, 2022, to April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vitamin injections received on March 10, 2022. 
 
You asked the Plan to pay for the injections. You say that there was no improvement from candle wax therapy 
and use of sequential compression devices. The Plan denied your request. The Plan says the records do not 
show an established diagnosis with confirmatory testing. 
 
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 pay for the injections. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no clear indication for these vitamin injections. There is no documentation of testing for 
vitamin deficiencies or a diagnosis requiring compression devices. There is no physical therapy documented. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pay for vitamin injections received on March 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 18, 2022, 
to March 19, 2022. 
 
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 NOA was not received timely. As such, this final claim was correctly denied. 
 
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 start of care date is February 18, 2022. The NOA was not received by the Plan until March 25, 
2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 18, 2022, to March 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room care (procedure code 99285) provided to 
the enrollee on August 9, 2022. 
 
You asked the Plan to pay for the servcies. You say that this shoul dbe paid for. The Plan denied your request. 
The Plan says there was no sign of complex system dysfunction, a condition that posed an immediate life 
threat, nor no acute situation of a complex nature to support the level of care billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 servcies. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined that the records did not support this level of care. The presenting problems were not of a high severity, posing an 
immediate significant threat. There was no complex medical decision making. The enrollee was 
hemodynamically stable, with normal vital signs and unremarkable lab work. No specialty consults or 
extensive decision making was required. No critical or extensive care was involved. 
 
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 servcies have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room care (procedure code 99285) provided to the enrollee on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that the records provided support the services. The Plan 
denied your request. The Plan says the services can be obtained from an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of 
service January 31, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, and 88360. You say that this was billed correctly. 
The Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
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 codes 88341, 88342, and 
88360. 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, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88341, 88342, and 88360 billed for date of service January 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the pelvis (72195) 
provided on July 1, 2022. 
 
You asked the Plan to pay for procedure code 72195. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that the MRI was billed with one or more diagnosis 
codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report left and right when a more specific bilateral diagnosis code is available. Therefore, we decided that the Plan does not 
have to pay for the magnetic resonance imaging (MRI) of the pelvis (72195) provided on July 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
June 21, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that these services 
should be covered in full. 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 a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room (ER) visit. This item/service falls within 
the emergency 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 emergency room 
(ER) visit provided on June 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the knee (73700). 
 
You asked the Plan to pre-approve a CT scan of the knee. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan of the knee. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found if the MAKO device is not 
approved for the planned knee surgery, then the requested CT would not be 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 a CT scan of the knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the knee (73700).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that you need your prescription refilled by 
this provider. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
you can be treated within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient treatment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service November 5, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says this code is included 
in the facility payment and is not separately payable.  
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, 88342, and 
88360. 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, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was ordered by a network doctor and 
should be paid. 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 March 23, 2022.