Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 6, 2022. 
 
You asked the Plan to pay for ambulance services. You say that you had billed the claim to hospice, and they 
denied the claim as not being related to the enrollee's hospice diagnosis. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the wellness visit provided on September 26, 2022. 
 
You asked the Plan to pay for the wellness visit. You say that the doctor did not mention that you only had one 
annual wellness visit per year. The Plan denied your request. The Plan says that the number of units exceeds 
the acceptable maximum. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The service at issue was rendered by a contract provider. The file does not show that the Plan provided notice 
that the wellness visit would not be covered. Under Medicare rules, this means the wellness visit is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the wellness visit provided on 
September 26, 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: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device provided on April 22, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were able to stop physical therapy. The 
Plan denied your request. The Plan says you do not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We find that a cervical traction device, coded E0856, was provided. We looked at the file, and Medicare rules. 
The medical records do not show that you have a musculoskeletal or neurologic impairment that requires 
traction. There is no documentation that the appropriate use of a home device has been demonstrated. 
Furthermore, the device, billed with code E0856, is considered not reasonable and necessary.  Based on this information, we decided that Medicare rules for coverage of the device have not been met. 
Therefore, we decided that the Plan does not have to pay for the cervical traction device provided on April 22, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen, 
an MRI of the pelvis, and a magnetic resonance cholangiopancreatography (MRCP) of the liver and pancreas. 
 
You asked the Plan to pre-approve the MRI of the abdomen, the MRI of the pelvis, and the MRCP of the liver 
and pancreas. You say that the requested services are medically necessary. The Plan denied your request. The 
Plan says the requested services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI of the abdomen, the MRI of 
the pelvis, and the MRCP of the liver and pancreas. Our reviewer says that the MRI of the abdomen, the MRI 
of the pelvis, and the MRCP of the liver and pancreas is not medically necessary. Our physician reviewer found 
that per provided coverage criteria, as well as eviCore standard of care guidelines AB 27.1, the enrollee's 
available records do not support concern for biliary pain, abnormal liver function tests, pancreatitis of any 
cause, nor abnormal prior imaging showing dilated pancreatic duct, enlargement, or fullness of the pancreas.  
 
The enrollee meets none of the coverage criteria for MRI or MRCP at this time. Indeed, not only is their 
clinical charting as provided inconsistent with their abdominal ultrasound report of a normal pancreas, but it 
also raises concern for the number of endoscopies performed to date. 
 
  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 MRI of the abdomen, the MRI of the pelvis, and the MRCP of the liver and 
pancreas have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic 
resonance imaging (MRI) of the abdomen, an MRI of the pelvis, and a magnetic resonance 
cholangiopancreatography (MRCP) of the liver and pancreas.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 30, 2021, to 
May 4, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the diagnosis is not validated in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code A41.9, defined as sepsis, unspecified 
organism. 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 inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the enrollee presented with shortness of breath, 
cough, and chills. Her vitals were stable. She was evaluated and treated for presumed pneumonia. In this case, 
there was no clinical or laboratory evidence of sepsis. The review has determined that the documentation did 
not support the billed diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 30, 2021, to May 4, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography (92250) and ophthalmological 
services (92004) provided on June 14, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the fundus photography and ophthalmological services. You say that according 
to your knowledge, an authorization is not required for a first time visit with a new patient. The Plan denied 
your request. The Plan says this visit was not an emergency, urgently needed care, or out-of-area dialysis, and 
an authorization was not obtained prior to services rendered from this OON 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 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 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 fundus photography (92250) and 
ophthalmological services (92004) provided on June 14, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra (LifeScan brand) diabetic testing 
supplies. 
 
You asked the Plan to pre-approve OneTouch test supplies. You say that you are appealing. The Plan denied 
your request. The Plan says this brand is not preferred by the Plan and the enrollee could use preferred-brand 
products such as Roche or Trividia Health products. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain DMEPOS 
brands.  
 
We looked at the file and Medicare rules. The requested OneTouch products are not one of the Plans preferred 
brands. The record does not include a reason why the enrollee cannot use a Plan-preferred brand. Based on this 
information, we decided that Medicare rules for coverage of OneTouch test supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra (LifeScan brand) diabetic 
testing supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on August 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the coding is appropriate. The Plan denied your 
request. The Plan says a condition code was not reported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that evaluation and management services, CPT codes G0463 and G0402, were billed on the same 
claim without a condition code. The remaining codes, 36415, G0103, 96077, and G0009, may be eligible for 
payment once the coding errors for codes G0463 and G0402 have been corrected. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for the outpatient hospital services provided on August 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 31, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy. 
 
You asked the Plan to pre-approve the therapy services. You say that you are a high risk for falls and could be 
back in the hospital if you don't get continuous therapy. The Plan denied your request. The Plan says criteria for 
medical necessity of therapy services has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the most recent documentation indicates that you continue to require 
minimum to contact guard assistance with mobility however, your level of mobility does not appear to have 
improved significantly. You may require assistance and supervision with mobility due to risk for falling, but 
this does not require the services of a skilled physical therapist. Therefore, the additional therapy cannot be 
considered 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Procrit or Retacrit before it will approve Aranesp. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 
enrollee does not meet the criteria for a step therapy exception for Aranesp. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Procrit or Retacrit. The record does not show that 
these drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 use of Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for admission to the LTACH. The Plan denied your request. The Plan says based on Medicare guidelines 
the long term acute care hospital services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital, having been 
admitted with COVID-19 and alcohol withdrawal. The enrollee was intubated/ventilated and eventually 
received a tracheotomy and feeding tube. There is no evidence that the enrollee requires services that are not 
currently available. Long term acute care hospitals and acute care hospitals are licensed to provide the same 
level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the 
current facility until such time no acute care services are required and can then be transferred to a lower level of 
care for any ongoing long term care needs.  
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 the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) and occupational therapy (OT) 
visits provided from May 13, 2022, to June 2, 2022. 
 
You asked the Plan to pay for the PT and OT visits. You say that you would like this claim to be processed 
accordingly. The Plan denied your request. The Plan says medical records were not provided for the dates 
appealed. The Plan also says that PT and OT notes were not provided, and medical necessity for this service 
cannot be established. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the PT and OT visits have been met. 
Medical records for the May 13, 2022, to June 2, 2022, dates of service were not provided for this case. The 
record shows that the Plan made multiple attempts to obtain this information, but it was not received. Without 
medical records, we are unable to determine if the provided services were medically necessary for the enrollee. 
Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) and occupational 
therapy (OT) visits provided from May 13, 2022, to June 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional $450 for the non-emergency ambulance 
transportation (A0426) provided on June 9, 2022. 
 
You asked the Plan to reimburse you an additional $450 for the non-emergency ambulance transportation. You 
say that the facility you were in ordered transportation for you to be taken home on your day of discharge. You 
also say that the administration did not check to see if the transportation company was in-network with your 
plan, and you had to pay the charge of $750 up front. The Plan denied your request. The Plan says the $450 
amount is the difference between the provider's charge and the amount allowed by your basic agreement. The 
Plan also says that you were reimbursed by the Plan at the allowed amount minus the $250 copayment which is 
your contractual responsibility. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency ambulance transportation have not been met. Specifically, the record indicates 
that the Plan has paid the Medicare allowed amount for this service. A Medicare provider should accept the 
Medicare allowed amount as payment in full. In this case, the Plan is not responsible for paying the balance 
that remains after the Medicare allowed payment. Therefore, we decided that the Plan does not have to 
reimburse you an additional $450 for the non-emergency ambulance transportation (A0426) provided on June 
9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that the claim denied as a need for medical records. 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 December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was incorrectly coded. You also say 
this visit was an emergency due to a crown that became loose and was painful. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 16, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on October 18, 2022.