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

 
We decided that the Plan does not have to pay for the home health services rendered from June 25, 2022, to 
July 22, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 25, 2022. The NOA was not received by the Plan until October 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from June 25, 2022, to July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 22, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that these services were not authorized. 
 
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 laboratory services provided on November 22, 
2022, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on January 18, 2022.  
 
You asked the Plan to pay for the ambulance transport. You say that this should be paid.  The Plan denied your 
request. The Plan says this was billed with a secondary diagnosis code that indicates noncoverage. In addition, 
the required -GY modifier was not billed.  
 
The Plan must follow Medicare rules. Medicare rules say that a secondary diagnosis code is required for 
ambulance claims. Code Z76.89 is to be used for patients who do not require an ambulance crew. Modifier -
GY should be used to denote noncoverage. 
 
We looked at the file and Medicare rules. The secondary diagnosis code reported indicates this is a noncovered 
transport. Based on this information, we decided that Medicare rules for coverage of the ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
provided on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from July 31, 2022, through August 3, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of A41.9 (Sepsis, unspecified organism). In this case, the documentation 
does not consistently and completely support the assigned secondary diagnosis code. The decision to remove 
the secondary diagnosis code and adjust the DRG is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code A41.9 rendered from July 31, 2022, through August 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (procedure code 99220) rendered on 
October 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99220 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99220. The documentation does not indicate the encounter required medical 
decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial observation care (procedure code 99220) rendered on October 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing provided during the outpatient hospital stay on October 
5, 2022, billed with code 83880. 
 
You asked the Plan to pay for the lab testing. You say that this is clearly necessary testing for a patient with 
shortness of breath.  The Plan denied your request. The Plan says that an appeal-level review was not 
completed as the time frame for doing so was missed.  
 
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 indicated that the diagnosis codes do not support payment for this 
service. However, the Plan did not provide a copy of the claim, so it is not possible to review all codes that 
were submitted. As such, the denial of payment is not substantiated. Therefore, we decided that the Plan has to 
pay for the lab testing provided during the outpatient hospital stay on October 5, 2022, billed with code 83880.  
 
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 pre-approve an office visit (99214) with a gynecology oncologist to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you require a gynecological physical 
examination every 6 months at this stage in your recovery, by an expert in detecting signs of reoccurring 
cancer. Not all gynecologists are oncologists and vice versa. You were previously told by the Plan that there 
were no providers available in-network. The Plan denied your request. The Plan says the latest medical records 
from your office visit on April 25, 2023, showed you are doing well after surgery for early endometrial cancer. 
No signs and symptoms noted to suggest recurrence. The request is for surveillance purposes. You can be seen 
by an in-network gynecologist who can monitor your condition and can refer you to a specialist, if needed in 
the future. 
 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 
an office visit (99214) with a gynecology oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical; colectomy, partial, with 
anastomosis, with coloproctostomy (low pelvic 
anastomosis) with colostomy. 
 
You asked the Plan to pre-approve a laparoscopy procedure. 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. 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 laparoscopy procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) at 
issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient, per Social 
Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). Provided records in this case do not 
document trial and failure of all standard medical (non-surgical) therapy for the enrollee's constipation. 
 
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 laparoscopy procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laparoscopy, surgical; colectomy, partial, with anastomosis, with 
coloproctostomy (low pelvic 
anastomosis) with colostomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health treatment. 
 
You asked the Plan to pre-approve inpatient behavioral health treatment. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active 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 inpatient behavioral health treatment. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review the records provided this enrollee does not meet criteria for acute inpatient mental health treatment as 
this enrollee was not shown to be a danger to himself or others. There were no auditory or visual hallucinations 
noted. He is cooperative and compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health treatment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic esophagogastroduodenoscopy (EGD). 
 
You asked the Plan to pre-approve a diagnostic EGD. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that EGD(s) for diagnostic purposes are covered under 
certain circumstances. 
 
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 diagnostic EGD. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the available documentation does 
not support that the diagnostic esophagogastroduodenoscopy at issue in this case was medically 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 a diagnostic EGD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a diagnostic esophagogastroduodenoscopy (EGD).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 4, 2022, to 
March 5, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 4, 2022. The NOA was not received by the Plan until July 30, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 4, 2022, to March 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the rhinAer radiofrequency ablation device. 
 
You asked the Plan to pre-approve the device. You say that the enrollee needs this procedure as part of their 
treatment.  The Plan denied your request. The Plan says studies have not proven this service is helpful for the 
enrollee.  
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found  there is no documentation that the radiofrequency ablation for the turbinates utilizing RhinAer 
at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. 
Provided medical records and review of the current peer-reviewed medical literature do not document that use of the radiofrequency ablation for the turbinates utilizing RhinAer has been shown in controlled studies in a 
Centers for Medicare & Medicaid Services (CMS)-approved journal to result in long term health benefits in 
patients with allergic and chronic rhinitis. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the rhinAer radiofrequency ablation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded with E0673 for November 10, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded with E0673 for 
November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be separately 
paid. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 14, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular procedures (37220, 37227, 37229, 37252, 
37253, 36200, 36245, 36246, 36247, 36248) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve vascular procedures. You say that the enrollee has been referred to other 
providers within the network, but none have offered treatment in a timely manner. The Plan denied your 
request. The Plan says the requesting provider is OON, and the enrollee does not have OON benefits. The Plan 
has in-network providers who can perform vascular procedures. 
 
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 
vascular procedures (37220, 37227, 37229, 37252, 37253, 36200, 36245, 36246, 36247, 36248) to be provided 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service November 1, 
2022. 
 You asked the Plan to pay for procedure code 99284. You say that the services should be paid as billed.  The 
Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service November 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral appliance provided on March 1, 2022.  
 
You asked the Plan to pay for the oral appliance. You say that this is a covered item and should be paid.  The 
Plan denied your request. The Plan says the criteria have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that oral appliance for sleep apnea may be covered 
when provided and billed by a licensed dentist. 
 
We looked at the file and Medicare rules. The file does not show that this device was provided and bill by a 
licensed dentist. Based on this information, we decided that Medicare rules for coverage of the oral appliance 
have not been met. Therefore, we decided that the Plan does not have to pay for the oral appliance provided on 
March 1, 2022.