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

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on December 
27, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care visits provided on December 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that you are in a lot of pain and 
need the requested services in order to move around better. The Plan denied your request. The Plan says 
ablation procedures are not supported by research to treat pain in the joint that connects the pelvis to the 
tailbone. 
 
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 radiofrequency ablation services. Our 
reviewer says that the requested radiofrequency ablation services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic left hip pain after a left 
hemiarthroplasty. She underwent diagnostic blocks of the articular branches of the femoral and obturator 
nerves with good results. There are no peer reviewed studies supporting the requested approach for treating of 
chronic post-operative hip pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit provided on July 14, 2022. 
 
You asked the Plan to waive the copayment for a podiatry visit. You say that you do not agree with the 
copayment. 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 $25 
copayment for Medicare-covered podiatry services. 
 
You have been asked to pay a $25 copayment for a podiatry visit. This item/service falls within the Medicare-
covered podiatry 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 waive the copayment for a podiatry 
visit provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the device. You say that the enrollee urgently needs this procedure due to 
worsening heart failure. The Plan denied your request. The Plan says CardioMEMS has been determined to be 
of uncertain value. 
 
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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289 and C2624).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on November 19, 
2022. 
 You asked the Plan to pay for paramedic intercept services. You say that you would like reconsideration 
because the requested paramedic intercept is medically necessary. The Plan denied your request. The Plan says 
the requested paramedic intercept is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on November 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter (K0800). 
 
You asked the Plan to pre-approve a motorized scooter. You say that the requested scooter is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 motorized scooter. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that there is no documentation that 
the electric scooter at issue in this case meets all Medicare criteria. The provided records document the electric 
scooter has been requested for "use outside of home, specifically for doctors, restaurants, etc." The records do 
not document the device is requested to improve participation in mobility related activities of daily living such 
as toileting, feeding, grooming, and bathing in customary locations within 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 motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a motorized scooter (K0800).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
November 29, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. The rules say that only an entity enrolled with Medicare as an OTP can bill 
these codes. 
 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on November 29, 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: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on September 9, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM service as billed. You say that this was billed correctly. The Plan denied 
your request. The Plan says the EM code selected 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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 EM service as billed. Our reviewer says 
that the billed EM code is not supported by the record. Our reviewer found the enrollee was seen due to chronic 
leg pain secondary to ischemia. There is no documentation of a detailed physical exam, such as reflexes, motor, 
sensory exam of the lower extremities. There is no detailed review of systems. There is no documentation of 
complex decision making. Switching from intravenous to oral opiates is not considered complex decision 
making. 
 
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 EM service as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient evaluation and management (EM) services provided on September 9, 
2022, billed with code 99223.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 30, 2022, 
to October 5, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
sepsis diagnoses are clearly supported in the record. The Plan denied your request. The Plan says the DRG 
payment was correctly adjusted. 
 
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 provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis code R65.20, defined as severe sepsis without septic shock. 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 reviewer says that the reported diagnosis codes at issue are not supported by the record. 
Our physician reviewer found the member is an 87-year-old female with a past medical history including prior 
stroke, dementia and hypertension who presented to the hospital with altered mental status. She was found to 
have symptomatic bradycardia with a urinary tract infection. She was treated for a low body temperature and 
started on antibiotics. She responded appropriately to treatment and stabilized. There was no evidence of life-
threatening organ dysfunction due to dysregulated host response to an infection or persistent hemodynamic 
instability. The documentation does not indicate that the treatment ordered by the treating medical providers 
supported a diagnosis code of A41.9 (Sepsis, unspecified organism) and R65.20 (Severe sepsis without septic 
shock).  
 
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 September 30, 2022, to October 5, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
December 1, 2021, through December 10, 2021, billed with code KBKE1. 
 
You asked the Plan to pay for the SNF services as billed. You say that these services were reported correctly 
and are supported in the medical record. The Plan denied your request. The Plan says the medical records do 
not support the PDPM code reported in this case, as the records do not support that a mechanically altered diet 
was provided. 
 
The Plan follows Medicare rules. Medicare rules say that payment for home health services is made through a 
HIPPS code which has five digits which correspond to different case-mix groups. The rules also say that active 
diagnoses are intended to code diseases that have a direct relationship to the residents current functional status, 
cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the 
important functions of the Minimum Data Set (MDS) assessment is to generate an updated, accurate picture of 
the residents current health status. 
 
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 SNF services as billed. Our reviewer 
says that the assigned speech pathology case-mix is not supported by the records. Our physician reviewer found 
the enrollee is a 79-year-old female with a medical history including Parkinson's disease, end-stage renal 
disease on hemodialysis, anemia and dysphagia who was admitted to a skilled nursing facility in December 
2021 after an acute hospital stay due to seizures. The 5-day MDS assessment indicates that the member 
required a mechanically altered diet and that this was provided. The documentation available for review does 
not support that the member received or required a mechanically altered diet. The 2nd alphanumeric character 
in the PDPM was not correct. The partial adjustment to PDPM KAKE1 was appropriate. 
 
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 services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from December 1, 2021, 
through December 10, 2021, billed with code KBKE1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0676. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that claims for E0676 will be statutorily denied as no 
Medicare benefit. 
 
We looked at the file and Medicare rules. The item at issue is a PCD coded E0676. This item is denied by 
Medicare as not covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (PCD) described by code E0676.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found there is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) retention. There are no pulmonary function tests to assess the severity of the COPD. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. If this enrollee does have chronic CO2 
retention, may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS) during sleep. Medicare does not cover a home ventilator when used at settings that can be 
provided with 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring of physiologic parameters (99453) 
provided on October 19, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99453 is remote monitoring of physiologic parameter(s) 
(eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use 
of equipment. 
 
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 service. Our reviewer found at issue is whether the 
requested authorization for reimbursement for remote monitoring of physiologic parameters is justified and 
substantiated by the documentation provided. While the patient has significant left ventricular dysfunction and 
intermittent atrial fibrillation, there is no supportive evidence provided to support the rationale for remote 
monitoring of physiologic parameters. Moreover, the documentation provided does not confirm that the 
service, remote monitoring of physiologic parameters (99453), was provided. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the remote monitoring of physiologic parameters (99453) provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cataract surgery provided on January 
12, 2022. 
 
You asked the Plan to waive the coinsurance for the cataract surgery. You say that this should be in-network. 
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 50% 
coinsurance for out-of-network outpatient surgery. 
 
You have been asked to pay 50% coinsurance for the cataract surgery. This item/service falls within the out-of-
network outpatient surgery 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 the cataract 
surgery provided on January 12, 2022.