Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on July 14, 2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you need the injections for your 
quality of life. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injections. This item/service falls within the Medicare 
Part B prescription drugs 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. The total you owe is $271.11 ($1,355.53 allowed amount x 20% = $271.11). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the injections provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 16, 
2023. 
 You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service July 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an upright walker provided on August 1, 2023, by an online 
retailer. 
 
You asked the Plan to pay for an upright walker. You say that you were unable to obtain an equivalent item 
from an authorized supplier. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an upright walker provided on August 1, 
2023, by an online retailer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310) and shoe holder pads (K0108). 
 You asked the Plan to pre-approve the services. 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. Medicare rules say that items and services that are not medically 
necessary are 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. There is not a medical need for the upgraded electronics or the shoe holder pads. 
 
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 an electronic connection between wheelchair controller and one power seating system 
motor (E2310) and shoe holder pads (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve wheelchair repairs. You say that you disagree with the denial. The Plan 
denied your request. The Plan says repairs cannot be covered for previously denied equipment. 
 The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that the Plan does not pay for repair of previously denied equipment.  
 
The request for repairs to the enrollees wheelchair cannot be covered. The records show that the enrollee was 
denied in December 2020 for this power wheelchair. The Plan does not pay for repair of previously denied 
equipment. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
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 require intensive physical therapy to regain 
strength, endurance, and mobility to remain independent once at home. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary, but skilled therapies as an outpatient or at a skilled nursing 
facility (SNF) may be approved upon request.  
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. The enrollee does 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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 federally qualified health center mental health visit, and 
the psychotherapy services provided on July 24, 2023. 
 
You asked the Plan to pay for the federally qualified health center mental health visit, and the psychotherapy 
services. You say that you are requesting reconsideration of the denied claim. The Plan denied your request. 
The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the federally qualified 
health center mental health visit, and the psychotherapy services provided on July 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are requesting reconsideration 
supported by the medical records. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records document facet arthrosis and other degenerative changes on 
spinal imaging which may be the cause of the enrollee's back pain. The provided records in this case do not 
document the Intracept procedure meets Medicare criteria for safe, effective, reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scans of the extracranial arteries, lower extremity 
arteries or arterial bypass grafts and the aorta billed with codes 93880, 93925 and 93978 provided on 
November 24, 2022. 
 
You asked the Plan to pay for the duplex scans. You say that the services were billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed services cannot be verified due to conflicting dates 
of service. The medical records show another date and not the date of service in question. 
 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 duplex scans have been met. the 
medical records provided do not have the date of service that the provider is appealing. Therefore, the billed 
services cannot be verified. The Plan indicated that they have made multiple attempts to contact the provider 
for additional information. Therefore, we decided that the Plan does not have to pay for the duplex scans of the 
extracranial arteries, lower extremity arteries or arterial bypass grafts and the aorta billed with codes 93880, 
93925 and 93978 provided on November 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on October 11, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on October 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT scan) of the abdomen and pelvis and the 
clinical decision support billed with codes 74177and G1004 provided on July 15, 2023. 
 
You asked the Plan to pay for the CT scan and clinical decision. You say that the services were billed correctly 
and should be paid. The Plan denied your request. The Plan says that technical components must be billed by 
the facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
Also, codes 74177and G1004 were billed by another provider for the same date of service and were paid. 
 
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. We find that the Plan did not provide a rule that disallows two CT scans from 
two separate facilities. Therefore, we decided that the Plan has to pay for the computed tomography (CT scan) 
of the abdomen and pelvis and the clinical decision support billed with codes 74177and G1004 provided on 
July 15, 2023.  
 
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 the emergency department (ED) services provided on June 
21, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 21, 2023.
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 the enrollee has rehabilitation goals that include 
returning to prior level of function with assistance/care provided by family,  and current needs cannot safely be 
met at a lower level of care. The Plan denied your request. The Plan says the enrollee's condition does not meet 
all the requirements for inpatient rehabilitation admission. The Plan says services may be provided at a lower 
level of care.  
 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies as an 
outpatient, home with home healthcare, or at a skilled nursing facility (SNF) may be approved upon request.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for cervical spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does 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. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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 office visit (99214) intravenous infusion, for 
therapy, prophylaxis, or diagnosis; initial, up to 1 hour (96365) intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug) (96366) and refilling and maintenance of implantable pump or 
reservoir (96521) provided on June 13, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the outpatient visit. You say that please see attached documentation for codes 
99214, 96365, 96366, and 96521. 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 the outpatient office visit (99214) intravenous 
infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour (96365) intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug) (96366) and refilling and maintenance of implantable 
pump or reservoir (96521) provided on June 13, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
October 18, 2022. 
 
You asked the Plan to pay for procedure codes 88342 and 88341. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 88342 is bundled into payment for code 
88189. 
 
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 88342 
is a column II code to column I code 88189. This claim has not been billed with an appropriate modifier to 
bypass the edit. As the primary code was denied, we have confirmed that code 88341 is an add-on code and has 
not been billed with an appropriate primary procedure code. 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 88342 
and 88341 billed for date of service October 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that Z95.0 has an Excludes1 note in relation to Z95.810. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on June 2, 2023.