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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, (A0428) and ground mileage (A0425) for 275 miles provided on August 20, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport, (A0428) and 
ground mileage (A0425). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says this is not covered. The Plan also says this claim does not meet requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 Ambulance service, basic life support, non-
emergency transport, (A0428) and ground mileage (A0425). Our reviewer says that the service is not medically 
necessary. Our physician reviewer found the enrollee was not bedbound, as evidenced by her ability to walk. 
Our physician reviewer also found that the enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Finally, our physician 
reviewer also found that transportation could have been provided by other means (stretcher van, wheelchair 
van, private care, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ambulance service, basic life support, non-emergency transport, (A0428) and 
ground mileage (A0425) have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance service, basic life support, non-emergency transport, (A0428) and ground mileage (A0425) for 275 
miles provided on August 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve the injection. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our physician reviewer 
found three months have not passed since the first injection; therefore, at this time, the request is deemed not 
medically reasonable and 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 injection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99232) provided on 
March 21, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
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 (99232) provided on 
March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you 
do not meet the clinical requirements to be approved for the services. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that does not meet age requirement. Therefore, we 
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening.
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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the denial of the 
LTACH admission was appropriate given the clinical scenario and the guidance presented. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99231 provided 
on June 8, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99231 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem 
focused interval history; A problem focused examination; Medical decision making that is straightforward or of 
low 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 patient is stable, recovering or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99231 is not supported in the medical record. Specifically, code G0378 was also billed 
for the same date of service. This means that the inpatient services identified with code 99231 are not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay 
for the subsequent hospital care services coded 99231 provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64561 billed for date of service October 11, 
2021. 
 
You asked the Plan to pay for procedure code 64561. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64561 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64561 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64561 billed for date of service October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that this doctor is close and offers 
services you and your family need. The Plan denied your request. The Plan says there are in-network 
provider(s) within a reasonable distance from your location that can provide this service or item. 
 
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 office services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that radiofrequency ablation is medically 
necessary. The Plan denied your request. The Plan says radiofrequency ablation does not meet the Medicare 
LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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. Our reviewer 
says that radiofrequency ablation is not medically necessary. Our physician reviewer found that in this case, 
there is no documentation provided indicating that the enrollee has had at least two (2) medically reasonable 
and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% 
sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used) and 
repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the enrollee had a minimum of consistent 50% improvement in pain for at least six (6) months or at 
least 50% consistent improvement in the ability to perform previously painful movements and activities of 
daily living as compared to baseline measurement using the same scale. The review has determined that the 
requested RFA does not meet the Medicare LCD coverage criteria 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammography (77067) provided on November 
11, 2021. 
 
You asked the Plan to pay for the screening mammography. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 5, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the screening mammography have not been 
met. Therefore, we decided that the Plan does not have to pay for the screening mammography (77067) 
provided on November 11, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve additional physical therapy (PT) services with the out-of-network 
(OON) provider specializing in neurological rehabilitation. 
 
You asked the Plan to pre-approve the OON neurological PT services. You say that you needed to go to a 
neurological PT provider and were paying out of pocket. You say that you can no longer afford to do this and 
that the Plan should approve these services as she requires additional care. The Plan denied your request. The 
Plan says that there are two network providers who offer PT that can be used by the enrollee. It is noted that 
there is no medical reason for the OON care to be approved. 
 
Please note: As noted below in the physician review, Maximus reviewed the websites of the two providers 
offered by the Plan. Neither provider lists neurological or stroke-related rehabilitation as one of the services 
available.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON neurological PT services. Our reviewer says that the requested PT services with the OON provider are shown to be medically reasonable and 
necessary. Our physician reviewer found that based on the medical records provided and information provided 
to this reviewer on the in-network and out-of-network therapy providers in this case, it does appear medically 
reasonable and necessary for the enrollee to be seen by a therapy provider with specialization in neurological 
conditions, including stroke. The information provided on the in-network therapy providers reports no specialty 
in stroke rehabilitation as opposed to the out-of-network provider. As the in-network provider does not appear 
to provide the necessary service, an exception to the in-network requirement appears indicated in this case due 
to the enrollee's "significant disability from the stroke."  
 
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 OON neurological PT services have been met. Therefore, we decided that 
the Plan has to pre-approve additional physical therapy (PT) services with the out-of-network (OON) provider 
specializing in neurological rehabilitation.  
 
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 radiology services (70450) provided on April 21, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was 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 the records show that the enrollee was an inpatient. 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 on April 21, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 10, 2022. 
 You asked the Plan to pay for the ambulance response. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 10, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment 
with no transport (A0998) provided on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63661 billed for date of service March 29, 
2022. 
 You asked the Plan to pay for procedure code 63661. You say that the services are supported in the medical 
records. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 63661 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 63661 billed for date of 
service March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge management (99239) billed for date of 
service February 3, 2022. 
 
You asked the Plan to pay for hospital discharge management. You say that discharge care has not been paid 
for this enrollee. The Plan denied your request. The Plan says discharge care billed with code 99238 has 
already been billed and paid for this enrollee for this hospital admission. Only one hospital discharge code is 
payable per stay. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that only one hospital discharge day management service is payable per patient per hospital stay.  
 
We looked at the file and Medicare rules. The record shows that code 99238 was billed by and paid to another 
provider in this facility for this enrollee with the same date of service/for the same stay. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge management have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital discharge management (99239) billed for 
date of service February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305, 88312, 88311, 87101) provided on 
August 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services should be covered. The Plan denied 
your request. The Plan says these services are not covered when provided OON 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab services (88305, 88312, 88311, 87101) 
provided on August 19, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring services provided on April 29, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services 
under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in 
full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients 
must be furnished directly by the hospital or billed through the hospital under arrangements. This provision 
applies to all hospitals, regardless of whether they are subject to PPS. 
 
We looked at the file and Medicare rules. Payment for the requested monitoring services is included in the 
facility payment. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for the monitoring services provided on 
April 29, 2022.