Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty wheelchair.
You asked the Plan to pre-approve a heavy-duty wheelchair. You say that this wheelchair is medically
necessary for this patient. The Plan denied your request. The Plan says there is no documentation that the
patient's home can accommodate the requested wheelchair. In addition, the medical records show that the
patient is currently ambulating independently.
The rules state that a manual wheelchair for use inside the home is covered if the beneficiary has a mobility
limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of
daily living (MRADLs).
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 heavy-duty wheelchair. Our reviewer
says that the patient does not meet criteria for a heavy-duty wheelchair. Our physician reviewer found the
documentation indicates the patient has a mobility deficit, but the medical progress notes do not specifically
discuss how this impairs MRADLs in the home. There is no detailed treating medical provider neuromuscular
exam of the upper extremities indicating or supporting why this patient is unable to use a walker. The
documentation is not clear that this wheelchair is for post-operative use or for lifetime use and the
documentation is not consistent whether this patient can safely maneuver this wheelchair in the home and that
it will significantly improve MRADLs in the home
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 heavy duty wheelchair have not been met. Therefore, we decided that the Plan
does not have to pre-approve a heavy-duty wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81226, 81227, 81230, 81231, 81240, 81241,
81291, 81328, 81335, 81355, 81479) provided March 22, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim cannot be paid 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 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81335, 81355, & 81479 is
not supported in the medical record. Specifically, multiple unbundled codes were billed for a single genetic
testing panel. A single procedure code should be reported for this service. 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 lab services (81226, 81227, 81230, 81231, 81240,
81241, 81291, 81328, 81335, 81355, 81479) provided March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient procedure services provided to the enrollee on
January 6, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says there were no medical records submitted with the claim to support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and provide medical records to support the services
billed. In this case, there were no records submitted to support the services billed. Medicare billing criteria are
not met. Therefore, we decided that the Plan does not have to pay for outpatient procedure services provided to
the enrollee on January 6, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the hip (73502) rendered by the out-of-
network (OON) provider on August 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the x-ray exam of the hip (73502) rendered by the out-of-network (OON) provider on
August 4, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided August 19, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim cannot be paid 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 70450 is not supported in the medical record. Specifically, the claim was billed with an
outpatient place of service (22), however records show the enrollee was an inpatient at the time services were
provided. Based on this information, we decided that Medicare rules for coverage of the radiology services
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70450)
provided August 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services (88305, 88312) provided on June 21, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of
network provider, without prior authorization.
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 provider in this case was referred for these services by a plan contract provider. The file does not show that
the plan provided notice that these services would not be covered. Under Medicare rules, this means these
services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory
services (88305, 88312) provided on June 21, 2021.
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 waive the coinsurance for a lumbar orthosis provided on July 15,
2021.
You asked the Plan to waive the coinsurance for the lumbar orthosis. You say that there should not be a charge
since it is for lymphoma, not a back injury. The Plan denied your request. The Plan says the correct
coinsurance was applied.
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 20%
coinsurance for each durable medical equipment (DME) item.
You have been asked to pay $180.70, which is 20% of the allowed amount for the lumbar orthosis ($903.52
allowed amount x 20% coinsurance = $180.70). The lumbar orthosis falls within the Durable Medical
Equipment (DME) and Related Supplies 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 coinsurance
for a lumbar orthosis provided on July 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two ambulance trips you received on
July 1, 2021.
You asked the Plan to waive the copayments for the two ambulance trips. You say that you should not have to
pay two copayments since you should have been taken to the correct hospital the first time. You said that it was
not your fault that the first emergency room had no one who could treat your injuries. The Plan denied your
request. The Plan says you were charged these copayments 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 $300
copayment per one-way trip for ambulance services.
You have been asked to pay a $300 copayment for each of the two ambulance trips. These copayments apply
regardless of the reason for the transports. 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 copayments for the two
ambulance trips you received on July 1, 2021.
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 the documentation does not support that you require services at the LTACH that are
not available at the acute care hospital where you are currently receiving care. The documentation does not
support that an additional 25 days of hospitalization are reasonably expected for you. Consequently, the
requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and
condition at this time.
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: SNF
Decision: Partially Favorable

You asked the Plan to waive the copayment for SNF care. You say that you were told that there would be no
charges for this stay, and you are on a fixed income. The Plan says that the copayment amount you are being
charged is correct.
We decided that the Plan has to reduce the copayment for SNF care.
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 $20
copayment per day for days 1 to 20, $140 copayment per day for days 21 to 44, and $0 copayment for days 45
to 100 of a benefit period for SNF care.
The claims at issue in this case are for date of service December 29, 2020 and for date of service January 1,
2021. The stay on December 29, 2020 lasted 1 day, resulting in a copayment amount of $20. The stay on
January 1, 2021 lasted 1 day, resulting in a copayment amount of $20. For each claim, the provider billed a
single date of service but billed multiple units (days) of SNF care. This is a billing error, as days of SNF care
should not be billed which are not reflected in the dates of service of the claim. This provider is in-network
with the Plan; therefore, you should not be held responsible for the provider's billing error as it is the
responsibility of the Plan to ensure proper billing of claims before asking you to pay cost-sharing for covered
services. If the Plan determines that a billing error has been made, this error must be corrected before they ask
you to pay cost-sharing for the services. Therefore, you can only be asked to pay cost sharing for the 2 days
that are actually reflected in the claims at issue, namely December 29, 2020 and January 1, 2021. Your total
copayment amount is therefore $40.
The Plan says that you must pay $1,215 copayment for SNF care. Based on the Plan contract and the claims at
issue in this case exactly as they have been billed, however, you cannot be asked to pay more than $0
copayment. Therefore, we decided that the Plan has to waive the copayment for SNF care.
We also decided that the Plan does not have to waive the copayment for SNF care.
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 $20
copayment per day for days 1 to 20, $140 copayment per day for days 21 to 44, and $0 copayment per day for
days 45 to 100 of a benefit period for SNF care. There were 2 days of SNF care, resulting in a copayment
amount of $40. Therefore, we decided that the Plan does not have to waive the copayment for SNF care.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on July
24, 2021.
You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level
of service. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because code 70450 has a procedure-to-procedure (PTP) edit with code 70496 and is not separately payable
without an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code CT
scan 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450)
provided on July 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for closed treatment of a fractured finger
(26740) provided on September 20, 2021.
You asked the Plan to waive the copayment for treatment of a fractured finger. You say that the services should
be covered as you were seen quickly and all they did was an x-ray and tape your fingers together. The Plan
denied your request. The Plan says the copayment applied correctly based on the services provided.
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 $275
copayment for Outpatient hospital services.
You have been asked to pay a $185.18 copayment for treatment of a fractured finger, which is less than the
$275 stated in the Plan's contract. Treatment of a fractured finger falls within the Outpatient hospital services
benefit category. The record indicates that these services were performed in an outpatient setting. 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 closed treatment of a fractured finger (26740) provided on
September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology gene expression profile testing (0089U-XS) March
11, 2021.
You asked the Plan to pay for oncology gene expression profile testing. You say that the documentation
supports that 2 tests were utilized for 2 separate body sites. The Plan denied your request. The Plan says the
denial of payment for this testing is correct, because the record supports 1 unit of 0089U which the Plan
already paid so an additional unit is 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 0089U-XS is oncology (melanoma), gene expression
profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es).
The definition of modifier -XS is separate structure, a service that is distinct because it was performed on a
separate organ/structure.
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 oncology gene expression profile testing. Our reviewer says
that this code does not meet the criteria for payment. Our reviewer found the laboratory report documents
"Eyebrow, Right Lateral." The documentation does not support that a second structure was tested. Modifier -
XS should not be used to bypass a National Correct Coding Institute (NCCI) procedure-to-procedure (PTP) edit
unless the proper criteria for the modifier is met. The medical documentation must satisfy the required criteria.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of oncology gene expression profile testing have not been met. Therefore, we
decided that the Plan does not have to pay for oncology gene expression profile testing (0089U-XS) March 11,
2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
September 1, 2021.
You asked the Plan to pay for the complete series of x-rays. You say that these x-rays were necessary for a full
evaluation. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
complete series of intraoral x-rays (D0210) provided on September 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that you need to be treated in the
SNF setting. The Plan denied your request. The Plan says your records do not show that you require daily
skilled services that can only be provided on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the
hospital on 12/13/2021 due to hypotension with adrenal insufficiency and possible medication non-compliance.
The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled
therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to
prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be
provided at a lower level of care.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0673, E0675) provided
June 7, 2021.
You asked the Plan to pay for the pneumatic compression devices. You say that the services were medically
necessary. The Plan denied your request. The Plan says the items were used in a hospital. Payment for this item
is included in payment to the facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that the pneumatic compression devices was used in a SNF or hospital. Therefore, we decided
that the Plan does not have to pay for pneumatic compression devices (E0673, E0675) provided June 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care provided from July 8, 2020, to July 31,
2020.
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied
your request. The Plan says the denial of payment for these services is correct, because this claim was not
submitted with the required code 85 data element.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be submitted with code
85 indicating the place of resident where the home health services were delivered.
We looked at the file and Medicare rules. These services were not billed with the required code 85 data
element. Based on this information, we decided that Medicare rules for coverage of home health care have not
been met. Therefore, we decided that the Plan does not have to pay for home health care provided from July 8,
2020, to July 31, 2020.