Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 30, 2022, to 
May 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 30, 2022, to May 
24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider depends on the facility staff to 
verify eligibility and obtain proper authorization from the enrollees insurance carrier. The Plan denied your 
request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care (99309) provided on April 
27, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided on 
April 1, 2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility services. 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 $400 
copayment per day for days 21 to 100. for Skilled nursing facility care. This skilled nursing facility care stay 
lasted 28 days, resulting in a copayment amount of $400 ($50 copayment per day for 8 days = $400). 
 
You have been asked to pay $400 copayment per day for days 21 to 100. for skilled nursing facility services. 
This item/service falls within the Skilled nursing facility 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 services provided on April 1, 2022, to April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that seen this doctor in the past and this doctor knows your situation and is familiar with 
your medical history. The Plan denied your request. The Plan says the medical care you require can be 
provided by a network provider. You must receive your care from a network provider. In most cases, care you 
receive from an out-of-network provider will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from March 4, 2022, to April 2, 
2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this claim was submitted with an inappropriate admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving home health 
services in 2021 whose services will continue in 2022, the home health agency (HHA) shall submit a Notice of 
Admission (NOA) with a one-time, artificial admission date corresponding to the From date for the first 
period of continuing care in 2022.  
 
We looked at the file and Medicare rules. This claim was billed with an admit date of October 5, 2021, but if 
care from 2021 was continuing into 2022 the claim should have been billed with an artificial admission date 
corresponding to the From date of the first period of continuing care in 2022. Based on this information, we 
decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the 
Plan does not have to pay for home health care provided from March 4, 2022, to April 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 3, 2021, 
to February 17, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 698. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the billed DRG is not supported. Our physician reviewer found that the enrollee presented to the hospital 
and was diagnosed with dehydration and urinary tract infection. Evaluation revealed Cr of 0.78 but later 
increased to 1.5-1.9 possibly related to medication side effect unrelated to the infection which was improving. 
She was found to tolerate room air. The enrollee was exhibiting signs of dementia during the hospitalization, 
which was chronic. Other testing did not reveal any organ dysfunction. Based on the provided documentation, 
there is insufficient evidence of sepsis based on the Sepsis 3 criteria and so the code, and DRG 698 is not 
supported by the records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on February 3, 2021, to February 17, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical supply services coded A4649 provided on May 
5, 2022. 
 
You asked the Plan to pay for the surgical supply services coded A4649. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this procedure code is 
bundled into payment for other services not specified and no separate payment is made per Medicare. 
 
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 A4649 is surgical supply; miscellaneous. 
 
We looked at the file and Medicare rules. In this case, code A4649 has a Status Code P under the Physician 
Fee Schedule indicating it as a Bundled/Excluded Code. This Status Code indicates that no separate payment should be made for this service under the fee schedule. Based on this information, we decided that Medicare 
rules for coverage of the surgical supply services coded A4649 have not been met. Therefore, we decided that 
the Plan does not have to pay for the surgical supply services coded A4649 provided on May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
You asked the Plan to pre-approve Myobloc. You say that the requested drug is not medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Botox and 
Xeomin. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Myobloc. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no indication 
that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myobloc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myobloc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventive medicine counseling and/or risk factor reduction 
intervention(s) provided to an individual (separate procedure); approximately 15 minutes (COVID-19 
standalone counseling) provided on July 12, 2022. 
 
You asked the Plan to pay for preventive medicine counseling and/or risk factor reduction intervention(s) 
provided to an individual (separate procedure); approximately 15 minutes (COVID-19 standalone counseling). 
The Plan denied your request. The Plan says this service is not covered by Medicare. The current Ambulance 
Fee Schedule does not price the requested code as it is statutorily excluded and also does not meet the criteria 
for ambulance service. 
 
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 looked at the file and Medicare rules. In this case, CPT code 99401 has a Status Code of N under the 
Physician Fee Schedule. This means that this is a non-covered service not covered by Medicare. Therefore, we 
decided that the Plan does not have to pay for preventive medicine counseling and/or risk factor reduction 
intervention(s) provided to an individual (separate procedure); approximately 15 minutes (COVID-19 
standalone counseling) provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were appealing this denial. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of 
care such as a skilled nursing facility (SNF). 
 
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 you were admitted for weakness, hypoglycemia and encephalopathy. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not 
been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care 
such as at 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96361, 96374, 96375, 96367, and A4649 
billed for date of service July 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the charges were appropriate for the level of 
services provided. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 96361, 96374, 96375, and 96367 have a PC/TC indicator of 5. No payment is made 
when services are provided in a hospital outpatient department. We find that CPT code A4649 has a status 
indicator of P. No separate payment is made for them under the fee schedule. 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 codes 96361, 96374, 96375, 96367, and A4649 billed for date of service July 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a screening colonoscopy. 
 
You asked the Plan to pre-approve a screening colonoscopy. You say that you want the Plan to approve this 
service. The Plan denied your request. The Plan says based on Medicare guidelines, you are not due for another 
screening colonoscopy until 2024. 
 
The Plan must follow Medicare rules. Medicare rules say that screening colonoscopy is covered at a frequency 
of once every 10 years for individuals who are not high risk.  
 
   
We looked at the file and Medicare rules. The documentation shows that you had a screening colonoscopy on 
July 1, 2014. The documentation also shows that you are not at high risk for developing colorectal cancer. 
Based on this information, we decided that Medicare rules for coverage of a screening colonoscopy have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a screening colonoscopy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation (CPT code 76376) provided on April 1, 2022. 
 
You asked the Plan to pay for the service. You say that the diagnosis is covered, and the service is billed 
correctly. The Plan denied your request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the file shows there was 
no documentation of an order for the 3D image nor documentation by the interpreting physician that the 3D 
interpretation was medically necessary. Therefore, we decided that the Plan does not have to pay for 3D 
rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, 
or other tomographic modality with image postprocessing under concurrent supervision; not requiring image 
postprocessing on an independent workstation (CPT code 76376) provided on April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (88360) provided on February 10, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The billed procedure 
code 88360-XU has a physician Fee Schedule PCTC indicator of 1 and the claim a POS of 22  On Campus-
Outpatient Hospital. The professional interpretation was furnished in the same payment locality from where the 
TC was furnished. We find that the Medicare rule for payment of this claim has not been met as the 
professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting 
physician. Therefore, we decided that the Plan does not have to pay for the laboratory service (88360) provided 
on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee wishes to continue using this device. 
The Plan denied your request. The Plan says the enrollee has been non-compliant with the non-invasive 
ventilator the enrollee has been using, nd the records do not show evidence of failure of continuous or bilevel 
positive airway pressure therapy. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ventilator. Our reviewer says that the 
enrollee does not meet criteria for continued use of a ventilator. Our physician reviewer found usage data from 
October 17, 2022, to November 16, 2022 show the enrollee used the device for at least 4 hours per day for 81% 
of days, which met Medicare minimum criteria. However, there is no arterial blood gas (ABG) done while stable as an outpatient to document continued chronic carbon dioxide (CO2) retention. If the enrollee does have 
chronic CO2 retention, the enrollee may benefit from bilevel positive airway pressure (BiPAP) therapy during 
sleep. This has not been tried as an outpatient. Medicare does not cover a home ventilator when used as a 
BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued use of a ventilator.