Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that bi-level positive airway pressure (BiPAP) 
will not work for you. The Plan denied your request. The Plan says the requested portable ventilator would be 
used in BiPAP mode that could be provided with a BiPAP device with average volume-assured pressure 
support (AVAPS.) 
 
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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. You have a diagnosis of chronic obstructive pulmonary disease (COPD), but spirometry 
on August 17, 2022, was normal, with Forced Expiratory Volume In 1 Second (FEV1) 87% predicted. An arterial blood gas (ABG) on March 21, 2022, at the time of admission for acute congestive heart failure (CHF) 
decompensation, was pH 7.42, pCO2 68.7, consistent with chronic oxygen (O2) retention. There is no ABG 
done more recently, while stable, to determine if you currently have chronic carbon dioxide (CO2) retention.  
With normal spirometry, COPD is unlikely to be the cause of CO2 retention.  You do not have thoracic 
restrictive disease or neuromuscular disease. You are reportedly intolerant of positive airway pressure (PAP) 
and bi-level positive airway pressure (BiPAP), so it is unlikely there will be tolerance of a non-invasive 
ventilator.  Medicare does not cover a home ventilator when used as 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology and anesthesia services provided to the enrollee on 
February 22, 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 the denied codes remain 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 the denied codes is: 
 
CPT 99100: 
 
Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to 
code for primary anesthesia procedure) 
 
 
 CPT 64999: 
 
Unlisted procedure, nervous system 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 99100 has a status indicator 
"B" which indicates that it is not separately reimbursable. In terms of CPT 64999, the procedure report does not 
include documentation of an unlisted procedure, nervous system. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurology and anesthesia services provided to the enrollee on February 22, 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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 that the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient's functional status including her weight bearing restrictions requires this therapy 
on an intensive IRF level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on October 13, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the outpatient services provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81225, 81227, 81230, 81231, 81232, 
81306, 81355, 81335, 0031U, 0032U, 0033U, 81291, 81238, and 81407) provided on February 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81291, 81238, 
and 81407) provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 12, 2022. 
 
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 Current Procedural Terminology (CPT) 
code 83789-59 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multianalyte assays with algorithmic analyses (81599) 
provided on March 16,2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that you are a reference laboratory and do not 
have face to face patient contact. Services were performed according to the request of the ordering physician. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 multianalyte assays with algorithmic analyses 
(81599) provided on March 16,2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 14, 2022. 
 
You asked the Plan to pay for physician's services. You say that the member presented with the incorrect 
insurance card at the time of service, and due to this the office was unable to obtain authorization. The Plan 
denied your request. The Plan says the services were not urgent or emergent in nature and the services could 
have been rendered by a Plan participating provider. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on April 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 1, 2022, to January 13, 2022. 
 You asked the Plan to pay for SNF care. You say that this should be paid for. The Plan denied your request. 
The Plan says a state Medicaid agency such as the Connecticut Department of Social Services is authorized to 
pursue Medicare claims for services provided to dually eligible Medicare and Medicaid beneficiaries and for 
which the state Medicaid program has paid. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from January 1, 2022, to January 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided the Plan does not have to pay for lab and physician services provided out of network on March 2, 
2022. 
 
You asked the Plan to pay for these services. You say that no one told you or your doctor why this provider is 
no longer in network. The Plan denied your request. The Plan says you did not have prior authorization in out 
of network care. 
 
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 had network providers available who could have provided the services at issue in this appeal. The 
Plan did not pre-approve the service at issue. Therefore, we decided that the Plan does not have to pay for lab 
and physician services provided out of network on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88361, 88312, 88305, and 88112) 
provided on February 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (88361, 88312, 88305, and 88112) provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON lab services. You say that this is a covered lab service and this test 
allows doctors to make informed decisions about the plan of care. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
Neither your lab nor the ordering provider in this case is 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 lab services provided on February 
22, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-invasive portable pressure RAD provided on February 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a non-invasive portable pressure RAD. You say that you do not agree with the 
denial of the claim and are requesting reconsideration. The Plan denied your request. The Plan says the 
payment was denied because there was no prior authorization on file and provider is not contracted with the 
Plan. 
 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 a non-invasive portable pressure RAD provided on 
February 18, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the OON lab services. You say that you believe the ordering doctor was a 
network doctor, so this should be covered as an in-network service. The Plan denied your request. The Plan 
says unauthorized, non-plan care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
Neither the ordering provider nor the lab in this case is 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 lab services provided on May 5, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the Rize adjustable bed purchased May 6, 2022. 
 
You asked the Plan to reimburse for the adjustable bed. You say that your need for an adjustable bed will never 
go away and you do not understand why the plan is denying the purchase. The Plan denied your request. The Plan says a hospital bed was authorized for rental not for purchase. The item purchased is specific brand and 
the Plan has an item that serves the same purpose available to you. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The Plan had approved for you to receive semi-electric hospital bed 
(E0260). Per the Plans approved authorization, this item was approved for rental from dates May 5, 2022 to 
July 9, 2023 and not for purchase. Based on this information, we decided that Medicare rules for coverage of 
the adjustable bed have not been met. Therefore, we decided that the Plan does not have to reimburse for the 
Rize adjustable bed purchased May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on March 7, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the services are tied to an authorized visit to the clinic. 
The Plan denied your request. The Plan says services rendered requires prior authorization. Prior authorization 
is not on file for the date of service listed above. The referring provider is not contracted with the Plan for these 
services that could have been provided by an in-network provider. 
 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 drug testing (G0483, 80307) provided on March 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care from December 7, 2020, through 
December 14, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the diagnosis of sepsis is supported by the 
documentation in the medical record and the denial should be overturned. The Plan denied your request. The 
Plan says the clinical documentation does not support diagnosis code A41.9. 
 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 diagnosis code A41.9-sepsis, unspecified organism. 
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 inpatient hospital care. Our physician 
reviewer found the review has determined that the documentation did not support the diagnosis code A41.9.  
 
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 inpatient hospital care from December 7, 2020, through December 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 13, 2022 to February 
17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says unauthorized, non-plan care is not 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 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 medical services provided on January 13, 2022 to February 17, 
2022, by an out-of-network (OON) provider.