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

 
We decided that the Plan has to pay for home health services provided from February 9, 2022, to March 10, 
2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says 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 rules also say that for home health services that are continuing from 2021, an 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. 
 
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's denial rationale is that the admission date on the claim 
for the services at issue does not match the admission date on the submitted NOA. However, the copies of the 
claim and NOA provided in the case record do not reflect any such discrepancy. The Plan has not provided any 
alternative rationales for denial. It is the Plan's responsibility to substantiate its denial with evidence. In this 
case, the Plan has not substantiated its denial, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for home health services provided from February 9, 2022, to March 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92960 and 93280 billed for date of service 
June 3, 2022. 
 
You asked the Plan to pay for procedure codes 92960 and 93280. The Plan denied your request. The Plan says 
payment for codes 92960 and 93280 is bundled into payment for code 93656.  
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 codes 
92960 and 93280 are column II codes to column I code 93656. 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 codes 92960 
and 93280 billed for date of service June 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service (A0999) provided on September 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ambulance service. You say that this is the only transportation service year 
you that would take you and your power chair, which you need to get around. The Plan denied your request. 
The Plan says you received non-emergency transportation services from a non-participating non-vendor 
provider. The Plan also says that you did not receive ambulance service, and an authorization is not on file for 
the non-emergency ambulance service. 
 
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 
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 ambulance service (A0999) provided on 
September 8, 2022, by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the records do not 
show that an intensive team is needed to reach the enrollee's functional goals. The enrollee may safely receive 
the services needed in a skilled nursing facility, home with home health and home physical therapy, or home 
with outpatient therapy. 
 
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 enrollee's medical conditions are stable and there are no complex nursing or 
rehabilitation needs.  
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has finished their physical therapy. The 
Plan denied your request. The Plan says there was no upper extremity testing and no notes of a nerve 
conduction study; therefore, the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the 
MRI of the cervical spine is not medically necessary. Our physician reviewer found that the enrollee had tried 
physical therapy with report of improved right-hand numbness/tingling. The MRI of the cervical spine was 
requested. However, the provided documentation did not include a detailed physical examination showing clear 
signs of radiculopathy following the trial of physical therapy. Also, the documentation shows the enrollee was 
improving with physical therapy which should be continued. Also, there was no results of nerve testing or 
evidence of a red flag diagnosis that might justify more immediate MRI testing. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgery provided on August 23, 2022. 
 
You asked the Plan to waive the coinsurance for surgery. You say that the ambulatory surgical center is in-
network. Therefore, the services should be covered. 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 50% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay 50% coinsurance for surgery. This item/service falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for surgery provided on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with 
calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says your request is not covered benefit because the enrollee's records show they do not have 
lymphedema extending onto the chest, trunk and/or abdomen, nor has the enrollee failed four-week trial of 
conservative therapy demonstrating failed response to treatment. 
 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 DME. Our physician reviewer 
found the enrollee did not exhibit signs of truncal edema/lymphedema nor was there report of failure of a more 
basic compression device in order to warrant use of this type of compression device. Therefore, the records do 
not meet the requirements listed in the Medicare rules. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code 
E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for procedure code 00400 billed for date of service April 
12, 2022. 
 
You asked the Plan to further pay for the billed service. You say that the hospital billed only for the medicine 
administered. The Plan denied your request. The Plan says the documentation does not support the additional 
units. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 00400 is anesthesia for procedures on the integumentary 
system on the extremities, anterior trunk and perineum; not otherwise specified. 
 
 We find that CPT code 00400 is not supported in the medical record. The records show that the Plan paid for 
118 units of procedure code 00400. The records do not support that an additional 23 units were provided. 
Based on this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to further pay for procedure code 00400 billed for date of 
service April 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74019 and 71045 billed for date of service 
June 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that these are separate and distinct procedures. The 
Plan denied your request. The Plan says the codes were replaced with a more appropriate code. 
 
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 codes 74019 and 71045 were replaced with code 74022. Providers shall bill with the most 
comprehensive code that describe the services provided. Therefore, we decided that the Plan does not have to 
pay for procedure codes 74019 and 71045 billed for date of service June 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Fasenra pen. 
 
You asked the Plan to pre-approve Fasenra. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Fasenra pen.  
 
  Benefits for Fasenra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on September 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. 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 office visit (99214) provided on September 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 26, 2022. 
 
You asked the Plan to pay for office visit. You say that the billed amount should be covered by insurance 
because you have been seen by an out-of-network provider previously. The Plan denied your request. The Plan 
says Medicare does not pay for any covered items or services you receive from an opt out doctor or other 
provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visit 
provided on July 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 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 pre-approve 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the outpatient services provided from January 14, 
2022, to July 20, 2022. 
 
You asked the Plan to reimburse you for the outpatient services. You say that you paid out of pocket for 
services that your plan said would be covered. You also say that you have paid $2,000 out of pocket. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
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 outpatient services have been met. 
Specifically, there were no itemized bills provided for the dates of service in this case. Without this 
information, we cannot determine if correct cost share amounts were applied to these services. Therefore, we decided that the Plan does not have to reimburse you for the outpatient services provided from January 14, 
2022, to July 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive metabolic panel (80053) provided on 
September 19, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the enrollee was not enrolled in hospice on 
this date. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the comprehensive 
metabolic panel (80053) provided on September 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is not medically necessary. 
 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 this item is not medically necessary. Our physician reviewer found you may benefit from BiPAP with 
AVAPS, with a backup rate, during sleep. This has not been tried and shown to fail as an outpatient. 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 (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair saddle bag (K0108). 
 
You asked the Plan to pre-approve a wheelchair saddle bag. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item does not primarily service a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair saddle bag (K0108).