Persius/hicric huggingface dataset:
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 do not have a vehicle and there is 
no reliable public transportation in your county. The Plan denied your request. The Plan says the denial of 
authorization for additional routine transportation is correct, because routine transportation beyond 24 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 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. At the time of the Plans decision, the 
Plan says that you have received 23 out of the 24 covered one-way trips. Based on this information, we decided 
that once you have received a total of 24 covered one-way trips you will exhaust 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge day management rendered on 
January 19, 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 procedure code 99217 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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]). 
 We find that CPT code 99217 is not supported in the medical record. Specifically, there is no documentation of 
a qualifying intial or subsequent observation care service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the observation care discharge day management rendered on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the records do not support payment for the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
September 28, 2021, have been met. In this case, no medical documentation indicating the results of the testing 
services were provided. Without these results, we cannot corroborate the services as billed.  Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on September 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says more skilled treatment is not needed at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the clinical documentation provided does not demonstrate that the 
unique skills of a professional therapist are required to safely in effectively provide the treatment requested. 
There is insufficient clinical documentation indicating that you are objectively improving in terms of outcome 
measures. The initial evaluation was performed on 10/20/2021 and there has been no subsequent re-evaluation 
to assess for improvement in strength, range of motion, and function. Without documentation of progress with 
physical therapy, you can continue with non-skilled therapy, or an independent exercise program. The 
requested physical therapy does not appear to be part of a maintenance program. The request to continue 
physical therapy does not meet guideline criteria in terms of documented progress with treatment. Therefore it 
cannot be considered medically 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the external ambulatory insulin delivery system 
(A9274). 
 
You asked the Plan to pre-approve the external ambulatory insulin delivery system. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this item is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. 
 
We looked at the file and Medicare rules. In this case, the requested external ambulatory insulin delivery 
system is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve the external ambulatory insulin delivery system (A9274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device provided to the 
enrollee on April 5, 2022. 
 
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. 
The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein 
thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. This was requested for prevention of deep vein thrombosis, or blood clots. Therefore, we decided 
that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee on April 
5, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for CxBladder Detect test (0012M) provided November 3, 2021. 
 
You asked the Plan to pay for CxBladder Detect test. You say that you believe that the evidence supporting the 
use of CxBladder Detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says that the documentation does not support that the services rendered were medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 CxBladder Detect test. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee meets the Medicare criteria for this test as it would lead to changes in testing and 
treatment following the results, has evidence to support it's use showing higher sensitivity than standard 
methods, and is listed as an approved testing option by the NCCN for similar clinical situations as this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CxBladder Detect test have been met. Therefore, we decided that the Plan has 
to pay for CxBladder Detect test (0012M) provided November 3, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued physical therapy services for the enrollee. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says no visits can be approved, as more skilled treatment is not needed at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 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 services. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist 
are required to safely and effectively provide treatment. There is inadequate documentation in terms of a 
physical examination with regards to motor strength, range of motion, and function. The initial physical 
therapy evaluation is not provided as a baseline in order assess for objective deficits and progress with 
objective outcome measures. The requested physical therapy is not part of a maintenance program. The 
requested physical therapy cannot be considered medically necessary given the fact that the guideline criteria 
have not been met. There is insufficient documentation regarding the patients physical examination findings, 
objective outcome measures and progress. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for continued physical therapy services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on October 18, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 domiciliary services provided on October 18, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear (code 85060) test provided on December 6, 
2021. 
 
You asked the Plan to pay for blood smear test. You say that you are appealing with evidence of medical 
necessity. The Plan denied your request. The Plan says the denial of payment for this test is correct, because 
this code was billed with an inappropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment for code 85060 may be made 
only if the physician interprets an abnormal smear for a hospital inpatient.  
 
We looked at the file and Medicare rules. This testing was performed on a hospital outpatient; therefore, no 
separate payment may be made for code 85060. Based on this information, we decided that Medicare rules for 
coverage of blood smear test have not been met. Therefore, we decided that the Plan does not have to pay for 
blood smear (code 85060) test provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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 August 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for out-of-network medical services provided on February 9, 2022. 
 
You asked the Plan to pay for the out-of-network medical services. You say that the patient has a Preferred 
Provider Organization (PPO) Plan, so this should be covered. The Plan denied your request. The Plan says that 
the patient had not yet met their out-of-network deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
contract documents that the Plan submitted in the case file to us explicitly state that there is no deductible for 
in-network and out-of-network services.  The Plan alleges that there is a $1,000 deductible for out-of-network 
services, but this is not reflected in the Schedule of Cost Sharing the Plan submitted with this case file.  The 
documentation submitted says that there is no such deductible, so there would be no valid rationale for the Plan 
assessing a deductible in this case. Therefore, we decided that the Plan has to pay for out-of-network medical 
services provided on February 9, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 31, 2021. 
 
You asked the Plan to pay for the x-ray. 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 chest x-ray (71045) provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00840) provided on December 27, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the provider was certified on the date of service 
and eligible to perform anesthesia services. The Plan denied your request. The Plan says that rules for payment 
have not been met. 
 
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 Plan has not provided a rationale why an anesthetist cannot 
provide the services at issue. It is the Plan's responsibility to substantiate its denial. In this case, the denial has 
not been substantiated and so we must find in your favor. Therefore, we decided that the Plan has to pay for 
anesthesia services (00840) provided on December 27, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on January 26, 2022 to 
February 1, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor billed procedure codes 99213 (office visit), 72100 (lumbosacral spine x-ray), and 72040 (neck 
spine x-ray). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on 
January 26, 2022 to February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77067, 77063) provided October 15, 
2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
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 77067, & 77063 is not supported in the medical record. Specifically, these services 
were paid in claim #40378202-00. Records do not support an additional instance of these services. 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 (77067, 77063) provided 
October 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from January 21, 2021, through 
March 12, 2021. 
 You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says you were only 
authorized for room and board until January 23, 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
The Plan contract covers SNF care. The Plan says prior authorization requirements may apply. 
 
We looked the file and the Plans rules. The file shows that the SNF stay was no authorized. Based on this 
information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we 
decided that the Plan does not have to pay for SNF services provided from January 21, 2021, through  
March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing provided on January 28, 2022. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for certain indications 
only. 
 
We looked at the file and Medicare rules. Review of the file shows that this testing was done immediately after 
the first prostate biopsy. The enrollee was not being considered for a second biopsy for persistent risk factors. 
Based on this information, we decided that Medicare rules for coverage of the ConfirmMDx testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on 
January 28, 2022.