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

 
We decided that the Plan does not have to pre-approve a ventilator (E0466 x3 units). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation of bilevel 
positive airway pressure (BIPAP) failure with or without average volume assured pressure support (AVAPS). 
Hence, home ventilator with Trilogy not indicated per documentations provided.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466 x3 units).
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to waive the charges for the inpatient physician evaluation. We decided that the 
Plan does not have to waive the charges for the emergency room visit.  
 
You asked the Plan to waive the charges for the emergency room visit and the inpatient physician evaluation 
provided on May 14, 2023. You say that you do not feel that you should have to pay the emergency room 
copayment because you were not treated and were just held until a bed opened up in another facility. You also 
disagree with the charge for an office visit because this doctor saw you in the hospital not an office. The Plan 
says that these charges were correctly assessed as your responsibility. 
 
We decided that the Plan has to waive the charges for the inpatient physician evaluation.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The contract says that there is no charge for inpatient professional 
services when provided in-network. 
 
Though this provider was out-of-network, the services were provided during a hospital stay related to an 
emergency. As such, the services should be processed as in-network, and the charge should be removed. 
Therefore, we decided that the Plan has to waive the charges for the inpatient physician evaluation.  
 
We also decided that the Plan does not have to waive the charges for the emergency room visit. 
 
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 a $95 
copayment for emergency room services. The rules also say that Medicare Part B does not cover self-
administered drugs in the outpatient setting. 
 
Though you state you were not treated in the emergency room, you were seen at an emergency room. As such, 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is 
contractual obligation you agreed to pay when you enrolled in the Plan. You were also given a self-
administered drug during this visit, for which you are charged $2. This type of drug is not covered by Medicare 
in an outpatient emergency room setting. Therefore, we decided that the Plan does not have to waive the 
charges for the emergency room visit. 
 
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 physician's services provided on May 24, 2023, by an  
out-of-network provider.  
 
You asked the Plan to pay for the physician's services. You say that you were in Florida and you were too sick 
to travel back to Rochester, New York to see an in-network provider, and at no time were you ever informed by 
your doctors that you needed an authorization for these treatments. You say had you been able to, you would have returned to New York to seek treatment with an in-network provider. The Plan denied your request. The 
Plan says you met your $5,000.00 out of pocket maximum on May 24,2023. 
 
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 contract with the Plan also says there is a POS plan 
coverage limit of $5,000 per calendar year. Once this limit is reached, you are responsible for 100% of the cost 
of out-of-network services. 
 
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 May 24, 2023, by an  
out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87506, 87324, 87500, and 87150 billed for 
March 4, 2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87506, 87324, 87500, and 87150 are not covered. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. The definition of code 87500 is infectious agent detection by nucleic acid 
(DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT codes 87506 and 87500 are not supported in the medical record. Specifically, the records 
show that 27 targets were tested and there is a more appropriate code for the services than code 87506. The 
records show that a panel was performed and there is a more appropriate code than 87500. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met.  
 
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 87324 
is a column II code to column I code 87506 and that code 87150 is a column II code to column I code 87500. 
This claim has not been billed with an appropriate modifier to bypass the edit. The -XU modifier is not 
supported as a separate and distinct procedural service. 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 87506, 87324, 87500, and 87150 
billed for March 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve D0150. You say that you need to see the endodontist before you receive 
your crown. The Plan denied your request. The Plan says the denied dental service is not a covered dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 30, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says we have insufficient documentation to corroborate the services so we 
cannot confirm Medicare coverage has been met. 
 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 physician's services have been met. 
Therefore, we decided that the Plan does not have to pay for physician's services provided on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee would benefit from a shower chair. 
The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87640, 87651, 87798, U0004, and U0005 billed for January 9, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 
87798, U0004, and U0005 are 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. 
 
We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798, U0004, and 
U0005 are not supported in the medical record. Specifically, a panel was performed and there is a more 
appropriate singular code for the services. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798, U0004, and U0005 
billed for January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789-59 billed for March 22, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 83789 is not separately payable.  
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 83789 is a column II code to column I code 80307; however, 83789 
was billed with a modifier.  
 
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 these services. Our reviewer says that the -59 modifier is not 
supported for code 83789. Our reviewer found the records include a urine drug screen with specimen validity 
testing. The specimen validity testing is included in the performed drug testing; therefore, the -59 modifier is 
not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 83789-59 billed for March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is limited data regarding the risks 
versus benefits, efficacy, and safety of electronic brachytherapy (EBT) in the treatment of early-stage non-
melanoma skin cancers (NMSC). Few non-randomized retrospective studies/case series showed that EBT is an 
effective and safe treatment option for NMSC. The services are not reasonable or medically necessary at this 
time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high dose rate electronic brachytherapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor.  
 
You asked the Plan to pre-approve a subcutaneous cardiac rhythm monitor. You say that the requested 
subcutaneous cardiac rhythm monitor is medically necessary. You say the NCD does not limit the terms of 
approval to just syncope, but of any transient, symptomatic arrhythmia, which may include atrial fibrillation. 
The Plan denied your request. The Plan says the clinical information provided to us shows no history of or 
recent episodes of syncope. 
 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 a subcutaneous cardiac rhythm monitor. 
Our reviewer says that the requested subcutaneous cardiac rhythm monitor is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the patient had no history of atrial 
fibrillation, nor were any significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. A 
recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed 
by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in 
reducing stroke or systemic embolism among patients at high risk of stroke but without a known prior history 
of atrial fibrillation. At this time, insertion of an ILR would not be considered medically appropriate and 
necessary in this patients clinical management. 
 
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 subcutaneous cardiac rhythm monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have documented skilled nursing needs. You are to receive daily intravenous 
(IV) antibiotics through November 15, 2023. Daily skilled services are required to establish a maintenance 
program or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport rendered on January 
18, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee was being discharged from 
the hospital and did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollees condition. The ambulance 
transport was not reasonable or medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the non-emergency ambulance transport rendered on January 18, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from April 21, 2023, 
through April 30, 2023, billed with payment code FALE1.  
 
You asked the Plan to pay for the SNF services as billed. You say that these services were authorized by the 
Plan and were medically necessary. The Plan denied your request. The Plan says that authorization was granted 
for HIPPS code FAPE, not the FALE1 that was billed.  
 
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. The Plan has not provided a valid denial rationale. The Plan has indicated that 
SNF care was authorized but that the claim is denied because the HIPPS code does not match the authorized 
code. The HIPPS code is calculated based on the actual findings and services rendered during the period of 
care. It would be expected that the presumed HIPPS code prior to care may differ from the code calculated 
once care has been provided. As such, this denial rationale is not valid. Therefore, we decided that the Plan has 
to pay for the skilled nursing facility (SNF) care provided from April 21, 2023, through April 30, 2023, billed 
with payment code FALE1.   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 billed for June 22, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 83520 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
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 these services. Our reviewer says that procedure code 83520 
is not supported. Our reviewer found the records do not include documentation to support the billed procedure 
code, as the specific name of the laboratory test(s) reported is not found.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 83520 billed for June 22, 2023.