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

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from November 30, 2021, to January 9, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you should not be responsible since 
there was a serious problem that was not taken care of. 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 $0 per 
day for days 1-20 and $160 per day for days 21-100 for each benefit period. 
 
Dates of Service Benefit Days Copayment 
November 30, 2021  December 19, 2021 1-20 (20) $0/day 
December 20, 2021  January 9, 2022 21-41 (21) $160/day 
Total:  $3,360 You have been asked to pay $160 per day for days 21-41 for the SNF care, for a total of $3,360. The SNF care 
falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility (SNF) care provided from November 30, 2021, to January 9, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services provided on 
January 12, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in 
hospice for this date of service.  
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 the hospital discharge day management services provided on 
January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant removal (20680) provided on May 11, 2021. 
 
You asked the Plan to pay for the implant removal (20680). You say that this procedure code is not considered 
inclusive with other procedures performed on this date of service when billed with the appropriate modifier. 
You say that nationally recognized entities agree the service is separately reimbursable and the claim needs to 
be recalculated to pay each procedure code. The Plan denied your request. The Plan says CPT code 20680 is 
included in CPT 27507 and cannot be separately reimbursed. 
 
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 20680 is a column II code to column I code 27507; however, 20680 
was billed with a modifier.  
 
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 implant removal (20680). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not support removal of implant as a separate distinct procedure from the primary 
procedure. The operative report describes removal of implant in same anatomical position as the primary 
procedure. In order to perform the primary procedure, the implant removal would need to be performed. 
Therefore, the implant removal would be inclusive to the primary procedure. 
 
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 implant removal (20680) have not been met. Therefore, we decided that the 
Plan does not have to pay for the implant removal (20680) provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a face-down positioning chair. 
 
You asked the Plan to pre-approve a face-down positioning chair. You say that this is medically reasonable for 
your condition. The Plan denied your request. The Plan says this device is statutorily non-covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a face-down positioning chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pulmonary equipment (E0466, E0483) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pulmonary equipment. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says this equipment is available from in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the pulmonary equipment (E0466, E0483) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation care provided from 
August 2, 2021, to August 4, 2021. 
 
You asked the Plan to waive the copayment for the observation care. You say that the hospital informed you 
that you would not have to pay for the overnight stay. 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 $275 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $275 copayment for the observation care. The observation care falls within the 
Outpatient Hospital Observation 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 
hospital observation care provided from August 2, 2021, to August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair. You say that you requested repairs and replacement parts 
which were approved, but have not been received as of yet, so you are requesting a new wheelchair. The Plan 
denied your request. The Plan says the denial of authorization for this device is correct, because the medical 
records do not include a full power wheelchair evaluation and statement of medical necessity and you are 
eligible for temporary rental of a power wheelchair while your wheelchair is being fixed. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of a durable medical equipment 
(DME) item may be covered if the item has exceeded its reasonable useful lifetime, has been lost, or has been 
irreparably damaged.  
 
We looked at the file and Medicare rules. The record does not show that your current power wheelchair has 
exceeded its reasonable useful lifetime, been lost, or been irreparably damaged. The Plan says that your 
wheelchair is currently undergoing repairs and that you can use a temporary wheelchair in the meantime. 
Please contact the Plan for more information about the status of your wheelchair. Based on this information, we 
decided that Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 10, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says testing in the absence of new signs and symptoms is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, Nodify CDT, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81479) provided on April 8, 
2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the claim has been billed with an 
inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. In this case, the claim has been submitted with a place of service of 
11 indicating the office setting. However, the medical records submitted do not indicate that the office setting is 
the most appropriate place of service where the services were rendered. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the genetic testing services (81479) provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 June 14, 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 enrollee currently meets LTACH 
admission criteria under the Centers for Medicare and Medicaid Services (CMS) guidelines. The Plan denied 
your request. The Plan says the medical records show that the enrollee does not meet Medicare guidelines, 
Medicare Claims Processing guidelines, or InterQual guidelines for care in a Long-Term Acute Care Hospital 
(LTACH). 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. Our physician reviewer also found that 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70480) provided on March 1, 2022. 
 
You asked the Plan to pay for the CT scan (70480). You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this 
code edit.  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 70480 
is a column II code to column I code 70450. 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 the CT scan (70480) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic agent injection (64450) provided on October 
13, 2021. 
  You asked the Plan to pay for the anesthetic agent injection (64450). You say that this charge is for a pre-
operative block that is given to manage post-operative pain and post-operative pain control is considered a 
separate procedure from the surgical procedure. You say that the claim should be reconsidered and payment for 
this procedure issued. The Plan denied your request. The Plan says an appropriate modifier was not billed with 
this code edit. 
 
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 64450 
is a column II code to column I code 01214. 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 the anesthetic agent injection (64450) provided on October 13, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the denial of authorization for additional routine transportation is 
correct, because routine transportation beyond 10 one-way trips per calendar year is not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the enrollee was 
informed that the requested item would be covered. The Plan denied your request. The Plan says rules for 
coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a group 2 support surface is covered if the enrollee 
meets at least one of the criteria set out in the Medicare rules section. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a powered pressure-reducing air mattress have not been met. Specifically, the available 
documentation does not show that the enrollee has pressure ulcers on the trunk or pelvis.  
 
 
 Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress 
(E0277).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex devcie is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. 
 
  
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the billed hereditary assessment for cardiac conditions. 
 
You asked the Plan to pay for the billed hereditary assessment for cardiac conditions. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says screening 
asymptomatic patients for cardiovascular risk is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the billed hereditary assessment for cardiac 
conditions. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee is a 65-year-old with a history of 
hypertension, hyperlipidemia, and elevated A1C on chronic steroids for Rheumatoid Arthritis. The enrollee 
underwent the hereditary assessment for cardiac conditions. There is no Medicare benefit for screening cardiovascular risk assessment testing for asymptomatic (without signs or symptoms of disease) patients. 
Screening asymptomatic patients for cardiovascular risk is statutorily excluded by Medicare. The review has 
determined that the items/services at issue in this case 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 the billed hereditary assessment for cardiac conditions have not been met. 
Therefore, we decided that the Plan does not have to pay for the billed hereditary assessment for cardiac 
conditions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36225) provided on January 
17, 2021. 
 
You asked the Plan to pay for the selective catheter placement (36225). You say that the operative notes should 
be reviewed, and the claim processed for reimbursement. The Plan denied your request. The Plan says 
procedure code 36225 is not supported by the medical records submitted. 
 
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 36225 is selective catheter placement, subclavian or 
innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated 
radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.  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 selective catheter placement (36225). Our reviewer says 
that the medical documentation does not support the use of procedure code 36225. Our reviewer found the 
documentation states the selective catheter placement of the innominate artery could not be completed due to 
angle after multiple attempts. Therefore, procedure code 36225 is not medically necessary as it was billed. 
 
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 selective catheter placement (36225) have not been met. Therefore, we 
decided that the Plan does not have to pay for the selective catheter placement (36225) provided on January 17, 
2021.