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

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product. 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product. 
You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says 
the requested services are experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous injection of allogeneic 
cellular and/or tissue-based product. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this is an 
experimental/investigational procedure. Therefore, the request is deemed 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 percutaneous injection of allogeneic cellular and/or tissue-based product have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of 
allogeneic cellular and/or tissue-based product.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 88341-XU, 88342-XU and 
88360) provided on July 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The billed procedure 
code 88341-XU,88342-XU and 88360 has a physician Fee Schedule PCTC indicator of 1 and the claim a POS 
of 21-Inpatient hospital. The professional interpretation was furnished in the same payment locality from where 
the TC was furnished. We find that the Medicare rule for payment of this claim has not been met as the 
professional interpretation of a diagnostic test must be separately billed with modifier - 26 by the interpreting 
physician. If the provider determines that a billing error occurred during the initial submission of the denied 
claim, the plan would accept a submission of a corrected claim to consider services for payment. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (CPT code 88341-XU, 88342-XU and 
88360) provided on July 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health physical therapy visits. 
 
You asked the Plan to pre-approve 4 home health physical therapy visits. 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 4 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for powered pressure-reducing air mattress (CPT code E0277-
RRKJKX) provided on July 25, 2021, and August 25, 2021. The Plan states that date of service February 25, 
2021, is being addressed as an appeal under another Plan case number.  
 
You asked the Plan to pay for the powered pressure-reducing air mattress. You say that the claim should be 
paid. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 powered pressure-reducing air mattress. 
Our physician reviewer found there is inadequate documentation indicating what stage the patients wound was 
after debridement of the hematoma and placement of the wound vacuum. The patient had a wound on the 
pelvis at the gluteal and hip region. However, there is no documentation regarding the staging of the wound as 
well as if there was an attempt to provide a treatment program which included did regular assessment, 
appropriate turning and positioning, and wound care. Therefore, the requested pressure reducing mattress was 
not medically necessary based on guideline criteria. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pay for powered pressure-reducing air mattress (CPT code E0277-
RRKJKX) provided on July 25, 2021, and August 25, 2021. The Plan states that date of service February 25, 
2021, is being addressed as an appeal under another Plan case number.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air fluidized bed (CPT code E0194) and trapeze bar, free 
standing, complete with grab bar (CPT code E0940) provided on September 23, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says they failed to review the case within the 60-day time frame allowed and we did not notify the 
appellant in a timely manner. 
 
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 air fluidized bed (CPT code E0194) 
and trapeze bar, free standing, complete with grab bar (CPT code E0940) provided on September 23, 2020. 
have been met. Review of the file shows that only a delivery ticket was provided. There is no other 
documentation included to verify the necessity of the DME. Therefore, we decided that the Plan does not have 
to pay for air fluidized bed (CPT code E0194) and trapeze bar, free standing, complete with grab bar (CPT 
code E0940) provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from July 21, 2021, through 
November 27, 2021, outside of the United States. 
 
You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says your request is not medically necessary because 
your records do not show that you have paid for these services in advance and the records do not indicate that 
you were hospitalized and there are no records from your providers stating that these were urgently-needed 
services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
The health plan contract says that you are covered for emergency care world-wide. If you have an emergency 
outside of the U.S. and its territories, you will be responsible to pay for the services rendered upfront. You must 
submit to the health plan for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
medical services provided from July 21, 2021, through November 27, 2021, outside of the United States.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are now in end-of-life care and are 
being taken off all of your medications and put on Morphine and Ativan. You say that, with your being taken 
off all your other medications for your heart, diabetes, blood pressure, and warfarin therapy, you are not 
progressing and need to stay in a SNF. The Plan denied your request. The Plan says the enrollee is on comfort 
care measures and does not require skilled nursing services or skilled rehabilitation services.  
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 continued SNF care. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee received oral 
medications and transition to comfort care. The enrollee received physical therapy and occupation therapy in 
the SNF and was discontinued, as he was unable to progress due to his medical condition. There are no 
identifiable skilled nursing or skilled therapy service needs. The enrollee does not meet the severity of illness 
or intensity of service criteria for an inpatient basis in a SNF 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) services.
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 enrollee is medically stable for rehabilitation and 
would benefit from IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not 
been met. The Plan says that the enrollee could receive care in another 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a ruptured bladder. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient hospital clinic visit provided 
on March 30, 2022. 
 
You asked the Plan to reduce the copayment for the outpatient visit. You say that your specialist copayment 
should only be $50. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each outpatient hospital visit.  
 
You have been asked to pay $115.98, which is less than the $300 copayment for the outpatient visit. The 
outpatient visit falls within the Outpatient Hospital Services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for an outpatient hospital clinic visit provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on January 19, 
2022. 
 You asked the Plan to pay for the outpatient hospital services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says multiple medical visits 
were billed on the same day without condition code G0 as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that outpatient claims will be subject to the OCE. 
 
We looked at the file and Medicare rules. In this case, the claim confirms that multiple medical visits have been 
billed on the same day with the same revenue code without condition code G0. OCE edit 42 is invoked when 
multiple medical visits are billed on the same day with the same revenue code without condition code G0. The 
required disposition for this claim with this edit is Return To Provider. This means the entire claim is returned 
to the provider for edits and will not be paid as billed. Based on this information, we decided that Medicare 
rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient hospital services provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket system. 
 
You asked the Plan to pre-approve a vacuum socket system. 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 follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and 
necessary if there is adequate documentation of functional and/or physiological need. 
 
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 vacuum socket system. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the literature reviewed 
indicates that further research is needed with clinical trials that recruit larger sample sizes and report long-term 
outcome data for the requested vacuum suspension system. 
 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 vacuum socket system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum socket system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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. 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
  
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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for COVID-19 at-home test kits provided on 
December 23, 2021. 
 
You asked the Plan to reimburse you for COVID-19 at-home test kits. The Plan denied your request. The Plan 
says you purchased at home COVID-19 test kits prior to when the benefit went into effect on February 1, 2022. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 at-home test kits have not been met. Therefore, we decided that the Plan does not have 
to reimburse you for COVID-19 at-home test kits provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on  
September 29, 2021. 
 
You asked the Plan to waive the copayment for the office visit. The Plan denied your request. The Plan says the 
claim processed 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 $50 
copayment for Physician/Practitioner services, including doctor's office visits-specialist office.  
 
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's office visits-specialist office 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 an office visit provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit (90832) provided on August 9, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service was provided out-of-network and was not approved in 
advance. 
 
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 psychotherapy visit (90832) provided on 
August 9, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have severe COPD with frequent 
exacerbations. There is mild CO2 retention on an ABG, but it is not clear whether this was done during an 
exacerbation.  You may benefit from bipap with AVAPS during sleep. This has not been tried at home. 
Medicare does not cover a home ventilator when used as bipap. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).