Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services and an 
outpatient diagnostic test provided on August 8, 2023, to August 18, 2023. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services and an outpatient diagnostic 
test. You say that you disagree with the copayment. 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 a $295 
copayment an outpatient diagnostic test/Medicare-covered diagnostic radiology and a $30 copayment for 
outpatient rehabilitation services.  You have been asked to pay a $295 copayment an outpatient diagnostic test and a $30 copayment for outpatient 
rehabilitation services. However, since the allowed amount is less than the standard copayment for the 
diagnostic test, you only owe $211.05. The total amount you are being asked to pay for the rehab services is 
$90 ($30 x 3 visits = $90). The total amount you are being asked to pay is $301.05 ($211.05 + $90 = $301.05). 
This item/service falls within the outpatient rehabilitation services and an outpatient diagnostic test/Medicare-
covered diagnostic radiology benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
rehabilitation services and an outpatient diagnostic test provided on August 8, 2023, to August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 9, 2023, billed with 
procedure codes A6446-AI (123 units) and A4450-AW-A1 (44 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes A6446-AI (123 units) and A4450-AW-A1 (44 units) is 
conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less 
than five inches, per yard, and tape, non-waterproof, per 18 square inches. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the provider reported 123 units for 
conforming bandage, however the physician order and delivery ticket documents 30. The provider reported 44 
units for non-waterproof tape, however the physician order and delivery ticket documents 1. As such, the units 
billed cannot be verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 9, 2023, billed with procedure codes 
A6446-AI (123 units) and A4450-AW-A1 (44 units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 13, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were 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 lab services provided on 
February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-adjunctive non-implanted continuous glucose 
monitor (CGM) receiver (E2103) and a supply allowance for a non-adjunctive non-implanted CGM (A4239). 
 
You asked the Plan to pre-approve a non-adjunctive non-implanted CGM and supplies. You say that the 
provider submitted medical records to support the appeal request for E2103 and A4239. The Plan denied your 
request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a non-adjunctive non-implanted CGM 
and supplies. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
coverage criteria for a CGM requires insulin use or low blood glucose sugar (BGS). The enrollee is not having 
low BGS that we are told of nor is he using insulin. Although the CGM may help the enrollee, coverage criteria 
are not met; we are also not told why a fingerstick meter would not suffice for this enrollee. 
 
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 non-adjunctive non-implanted CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a non-adjunctive non-implanted continuous 
glucose monitor (CGM) receiver (E2103) and a supply allowance for a non-adjunctive non-implanted CGM 
(A4239).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the injections. We decided that the Plan does not have to pre-
approve the moderate sedation.  
 
You asked the Plan to pre-approve facet joint injections with moderate sedation You say that the procedure 
requires delicate and precise placement of needles in the areas of the spine where severe complications can 
arise if a patient moves suddenly. You say that the procedures are quite painful and it unreasonable to subject 
patients to these procedures without appropriate comfort measures. The Plan says that facet joint injections 
with moderate sedation is not medically necessary.   
We decided that the Plan has to pre-approve the injections and does not have to pre-approve the 
moderate sedation.  
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not reasonable and 
necessary for facet joint interventions. 
 
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 item/service at issue. Our reviewer 
says that moderate sedation is not medically necessary and facet joint injections are medically necessary. Our 
physician reviewer found that there is no indication for sedation as the enrollee does not have an unstable 
medical condition, morbid obesity, obstructive sleep apnea or psychiatric issues. The request for repeat facet 
joint injections is medically reasonable and necessary and the moderate sedation request is not 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 the item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve the facet joint injections and does not have to pre-approve the moderate sedation.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214). 
 
You asked the Plan to pre-approve D5214. You say that you need this denture. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 22, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
testing provided on May 8, 2023, and billed with codes 87801, 87798, and 87481. 
 
You asked the Plan to pay for the fungal infection PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel testing provided on 
May 8, 2023, and billed with codes 87801, 87798, and 87481.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve intracept intraosseous nerve ablation system. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the requested 
service does not meet the requirements for approval. 
 
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 intracept intraosseous nerve ablation 
system. 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 magnetic resonance imaging (MRI) showing 
only modic changes without facet degenerative joint disease (DJD) or stenosis. The cause of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept intraosseous nerve ablation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system.
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 a history of above the knee 
amputation as well as a history of diabetes mellitus, hypertension, and peripheral artery disease. You also say 
that he would benefit from the close medical oversight offered only at the IRF. The Plan denied your request. 
The Plan says based on the available information, admission to IRF is not reasonable and necessary, as the 
enrollee's condition does not meet the Medicare rules.  
 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 forlimb ischemia and had an above the knee amputation, then was transferred to acute inpatient 
rehabilitation on August 28, 2023 and discharged home on September 9, 2023. He has recently received a new 
prosthetic leg. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 28, 2023, to 
June 2, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that J96.21 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says J96.21 is not supported in the documentation. 
 
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 principal diagnosis J96.21, defined as acute and 
chronic respiratory failure with hypoxia. 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 principal diagnosis J96.21 is not 
supported in the documentation. Our physician reviewer found the enrollee presented with a cough and 
shortness of breath, in the setting of chronic obstructive pulmonary disease (COPD) and home oxygen use. The 
enrollee was treated for a COPD exacerbation, while pneumonia and a pulmonary embolism (PE) were being 
ruled out. There is no evidence that the enrollee had acute respiratory failure. As such, the billing of J96.21 is 
not supported.  
 
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 provided on May 28, 2023, to June 2, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee can regain maximum 
function if approved for more days at the SNF. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare guidelines for continuation of services in the SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 inpatient rehabilitation facility services are 
medically necessary. The Plan denied your request. The Plan says the inpatient rehabilitation facility services 
are 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 The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network hammertoe repair procedure 
provided on July 21, 2023. 
 
You asked the Plan to waive the copayment for an in-network hammertoe repair procedure. You say that you 
should only have to pay the $50 specialist office copayment. 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 a $350 
copayment for outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters.  
You have been asked to pay a $350 copayment for an in-network hammertoe repair procedure. This 
item/service falls within the outpatient surgery, including services provided athospital outpatient facilities and 
ambulatory surgicalcenters benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network hammertoe repair procedure provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 18, 2023, billed with 
procedure code G0500-GC. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0500-GC is moderate sedation services provided by the 
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 
years or older (additional time may be reported with 99153, as appropriate).  
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that this procedure was a cardiac 
catheterization and while they did use moderate sedation this code is not the appropriate code to use. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 18, 2023, billed with procedure code 
G0500-GC.