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

 
We decided that the Plan has to pay for transplant-related transportation expenses provided from June 24, 2022, 
to July 1, 2022. 
 
You asked the Plan to pay for transplant-related transportation services. You say that you had to travel for a 
transplant and want reimbursement for the expenses. The Plan denied your request. The Plan says that the Plan 
has reimbursed you $1,029.60 based on distance you travelled, so additional reimbursement is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Plan covers transplant services at a distant 
location, it must provide reasonable transportation for the enrollee and a companion to the distant facility.  
 
We looked at the file and Medicare rules. You are requesting a reimbursement amount of $2,891.59 for your 
transportation expenses. The Plan has reimbursed you $1,029.60. The Plan based this reimbursement amount 
on the Internal Revenue Service (IRS) standard issue mileage rates for 2022, calculating the shortest possible 
distance between your home and the distant facility. However, the IRS standard issue mileage rate is an 
optional standardized figure intended only for use when calculating the tax-deductible costs of operating an 
automobile for medical purposes. Furthermore, this standard mileage rate has no jurisdiction over the Medicare 
program. Therefore, this is not a reasonable method for calculating transportation expenses to a distant 
transplant location. Additionally, the Medicare rules do not indicate that transportation expenses should be 
determined based on the shortest possible route to the distant transplant location. Therefore, it is not reasonable 
to ignore the actual transportation performed to reach the distant facility in favor of a hypothetically shorter 
route. The Plan has not shown that it is reasonable to cover an amount less than the full, actual transportation 
expenses you required to reach the distant transplant facility. Based on this information, we decided that 
Medicare rules for coverage of transplant-related transportation services have been met. The Plan must 
reimburse you an additional $1,861.99 to fulfill coverage of reasonable transportation to the distant facility. 
Therefore, we decided that the Plan has to pay for transplant-related transportation expenses provided from 
June 24, 2022, to July 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 1, 2022. 
 
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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 1, 2022.
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's medical needs warrant 
LTACH level of care and they meet the LTACH admission criteria. The Plan denied your request. The Plan 
says admission to an LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is presently receiving appropriate services in the acute care setting. 
Continued care in the acute hospital is appropriate until the enrollee is stable to transfer to 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that these lab services were medically necessary and 
should be covered. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair lift you purchased on May 31, 2022. 
 
You asked the Plan to pay for the stair lift. You say that the enrollee has had several aneurysms and cannot use 
the stairs.  The enrollee's room is on the second floor of the home, so it was necessary to purchase this stair lift. 
The Plan denied your request. The Plan says stair lifts are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for the stair lift you purchased on May 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (procedure codes 27236, 99222) provided to the 
enrollee on April 13, 2022. 
 
You asked the Plan to pay for the services. You say that the claim was denied in error. The Plan denied your 
request. The Plan says the enrollee was under the hospice benefit. 
 
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 services (procedure codes 27236, 99222) provided to the 
enrollee on April 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the inpatient rehabilitation stay is physically and 
medically necessary for the enrollee to return home at their maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the request is not medically necessary, the 
services the enrollee needs can be provided safely in other settings, for example, a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
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 genicular nerve ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had hip surgery and has been in the 
hospital for three weeks. You say the enrollee has low muscle tone and minimal mobility and needs 
rehabilitation to build their strength. The Plan denied your request. The Plan says the medical necessity for 
admission to an acute IRF has not been met. 
 
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 do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing billed with procedure code G0482 for date of 
service April 5, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says that the documentation does not include a 
current laboratory report with a breakdown of the drugs tested to obtain an accurate class count. Therefore, the 
record does not support that 15-21 drug classes were tested. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers, 15-21 drug class(es), including metabolite(s), if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab results report includes 
the names of individual drugs which were tested. If we exclude any drugs or classes labeled as a screening on 
this report, we can see that drugs from at least 15 but not more than 21 classes have been tested, including 
alcohol(s), alkaloids (not otherwise specified), antiepileptics (not otherwise specified), benzodiazepines, 
buprenorphine, fentanyls, gabapentin (non-blood), heroin metabolite, methadone, opiates, opioids and opiate 
analogs, oxycodone, pregabalin, skeletal muscle relaxants and tramadol. Based on this information, we decided 
that Medicare rules for coverage of definitive drug testing have been met. Therefore, we decided that the Plan 
has to pay for definitive drug testing billed with procedure code G0482 for date of service April 5, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9501 billed for date of service April 1, 
2022, to April 7, 2022. 
 
You asked the Plan to pay for procedure code S9501. You say that the S code is valid, and the claim should be 
reprocessed for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9501 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9501 billed for date of service April 1, 2022, to April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (procedure code 74250) provided to the 
enrollee on April 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
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 74250 
is a column II code to column I code 74240 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for radiology services (procedure code 74250) provided to the enrollee on April 
26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from January 
14, 2022, to February 7, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment for home health services have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving HH services in 
2021 whose services will continue in 2022, the HHA shall submit an NOA with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the Plan has documented that the date of 
admission on the claim for the period of care at issue does not match the date of admission on the submitted 
NOA. Therefore, we decided that the Plan does not have to pay for home health services billed for dates of 
service from January 14, 2022, to February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for cataract surgery and injection, 
dexamethasone provided on June 7, 2022. 
 
You asked the Plan to waive the cost share for cataract surgery and injection, dexamethasone. You say that you 
are disputing the share cost. 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 20% 
coinsurance for Medicare Part B prescription drug. The allowed amount of this injection total $475.64, 
resulting in a coinsurance amount of $95.13. 
 
You have been asked to pay 20% coinsurance and $200 copayment for cataract surgery and injection, dexamethasone. These items/services fall within the Medicare Part B prescription drug and outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
categories. 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 cost share for cataract surgery and injection, 
dexamethasone provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that the records provided support the 
need for the injection services in dispute. The Plan denied your request. The Plan says the records do not show 
that the requested injections are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that diagnostic procedures should be performed with the intent 
that if successful, RFA procedure would be considered the primary treatment goal at the diagnosed level(s). 
 
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 facet joint injection services. Our 
reviewer says that facet joint injection services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had 2 prior facet blocks, and each provided greater than 50% pain relief for more than 6 months. The request is to repeat the 
blocks rather than for RFA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.