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

 
We decided that the Plan does not have to pay for the home visit provided on March 07, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. 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 home visit provided 
on March 07, 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 services are medically necessary for you to 
receive the care needed. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93925 and 99215 for date of service March 
8, 2023. 
 
You asked the Plan to pay for procedure codes 93925 and 99215. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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 93925 and 99215 are not supported in the medical record. Specifically, the submitted 
medical records do not indicate that duplex scan of lower extremity arteries or arterial bypass grafts; complete 
bilateral study was performed on the billed date of service. The submitted medical records indicate that a 
limited study was performed. This means there is a more appropriate code to be billed for the services 
rendered.  The documentation does not support the time spent on the office or other outpatient visit; therefore, code 99215 
is not supported. Based on this information, we decided that Medicare rules for coverage of procedure codes 
93925 and 99215 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 93925 and 99215 for date of service March 8, 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 services are medically necessary because you 
want to make sure your health does not deteriorate any further. The Plan denied your request. The Plan says 
you do not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 provided on January 24, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 13 units of CPT code 87798 are not supported in the medical record. The medical record only 
supports 9 units of CPT code 87798. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87798 provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office and clinic visits to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve outpatient care. You say that the enrollee should continue care without 
interruption. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the 
enrollee can be treated within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office and clinic visits to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 29, 2022. 
 You asked the Plan to pay for the lab services. You say that the services provided were not related to the 
enrollee's terminal illness. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on December 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) and ultraviolet therapy (97028) 
provided from August 8, 2022, to September 10, 2022. 
 
You asked the Plan to pay for the infrared therapy and ultraviolet therapy. The Plan denied your request. The 
Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the 
symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory 
neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy and ultraviolet therapy have not been met. Therefore, we decided that the Plan 
does not have to pay for the infrared therapy (97026) and ultraviolet therapy (97028) provided from August 8, 
2022, to September 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wipes. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve wipes.
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 would benefit from intensive inpatient 
rehab services. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray provided on April 11, 2023. 
 
You asked the Plan to waive the deductible for the x-ray. You say that this service should be covered under the 
annual wellness visit. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to the in-network x-ray. Your contract 
with the Plan also clearly says that you must pay 10% coinsurance of the approved amount after deductible. 
 
 
 
 
 You have been asked to pay $85.43 towards your deductible for the x-ray. The item or service you asked the 
Plan to waive the deductible for falls within the outpatient hospital services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which applies to 
outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the x-
ray was received on April 11, 2023. Therefore, we decided that the Plan does not have to waive the deductible 
for the x-ray provided on April 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation to maximize their 
potential to return to their previous level of independence which they sincerely desires. The Plan denied your 
request. The Plan says an IRF admission 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan of the maxillofacial area. We 
decided that the Plan does not have to pay for an office visit.  
 
You asked the Plan to pay for an office visit and a computed tomography (CT) scan of the maxillofacial area 
provided on March 15, 2023. You say that you are appealing with supporting records. The Plan says that the 
services were provided by a dentist, thus they are not covered. 
 
We decided that the Plan has to pay for a computed tomography (CT) scan of the maxillofacial area.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for a computed tomography (CT) scan of the maxillofacial area by a contract provider. The 
file does not show that the Plan provided notice that a computed tomography (CT) scan of the maxillofacial 
area would not be covered. Under Medicare rules, this means a computed tomography (CT) scan of the 
maxillofacial area is considered approved by the Plan. The EOC clearly states that the Plan covers diagnostic 
services and other outpatient diagnostic tests. Nowhere does the EOC state that a dentist cannot perform these 
services. The EOC does not clarify what diagnostic services means. Therefore, we decided that the Plan has to 
pay for a computed tomography (CT) scan of the maxillofacial area.  
 
We also decided that the Plan does not have to pay for an office visit. 
 
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 office visit is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for an office 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service December 7, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service December 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as U0004 and U0005 provided 
September 1, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the claim was received after the timely 
filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until April 3, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the laboratory service coded as U0004 and U0005 provided September 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99221 and 99232 billed for dates of service 
March 27, 2023, to March 28, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. 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 providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 99221 and 99232 were billed with an inpatient place of service code (21). The 
enrollees claim information shows that the enrollee was in outpatient observation at the time the services were 
provided. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99221 and 99232 
billed for dates of service March 27, 2023, to March 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81225, 81226, 81227, 81231, 81232, 81240, 
81241, 81291, 81306, 81328, 81335, 81479, and 81238 for date of service February 27, 2023. 
 
You asked the Plan to pay for procedure codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 
81306, 81328, 81335, 81479, and 81238. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed.  
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 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 
81479, and 81238 are not payable as billed. Specifically, these services were billed with diagnosis codes 
G89.29 (Other chronic pain) and R52 (Pain, unspecified). Due to an Excludes1 note, these two diagnosis codes 
should not be billed together. The claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 
81306, 81328, 81335, 81479, and 81238 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 
81479, and 81238 for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 05, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. 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 laboratory services 
provided on January 05, 2023.