Persius/hicric huggingface dataset:
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 February 16, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests should be included in the dialysis rate. 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 
February 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the DME purchased on September 7, 
2022. 
 
You asked the Plan to provide reimbursement for the DME. You say that these items should be covered. The 
Plan denied your request. The Plan says the provider is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for the DME purchased 
on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physician office visit and related services to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a physician office visit and related services. You say that the requested 
services are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for 
OON services have not been met. 
 
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 
a physician office visit and related services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facedown recovery system (E1399) provided March 20, 
2023, to March 28, 2023. 
 
You asked the Plan to pay for the facedown recovery system. You say that the head down positioning 
equipment enabled you to remain in a head down position or the 7 days after having surgery. The Plan denied 
your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the facedown recovery system (E1399) 
provided March 20, 2023, to March 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 11, 2023, 
to March 12, 2023. 
 You asked the Plan to pay for the home health services . You say that the proper claims have been submitted. 
You state that other Medicare Advantage plans still require 30-day Requests for Anticipated Payment (RAP). 
The Plan denied your request. The Plan says an NOA has not been received by the Plan for this episode of care. 
 
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 January 12, 2023. An NOA has not been received by the Plan; only RAPs 
have been submitted. As more than 30 days passed since the period of care began, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
February 11, 2023, to March 12, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that admission to an IRF does not meet criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You require treatment by multiple therapies, including 
either physical therapy (PT) or occupational therapy (OT), and an intensive rehabilitation therapy program. Per 
Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall significantly 
complies with the various documentation requirements for IRF admission (e.g., as best summarized by PT note 
on July 25, and IRF evaluation on August 8). Indeed, your condition is in fact complex and fragile, and there is 
reason to question why you were not admitted to an IRF directly from the acute hospital. That notwithstanding, 
there remains every reason to expect that you will participate in and benefit from services to include at 
minimum PT, OT, physician oversight of post-op / cardiac risk factors and wound care, as well as case 
manager coordination of any additional services you might need to make a sustainable, more prompt return 
home than apparently can be accomplished from the skilled nursing facility (SNF). Therefore, the requested 
inpatient rehab facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 waive the cost share for the office visit and drug injection provided 
on July 27, 2022. 
 
You asked the Plan to waive the cost share for the office visit and drug injection. You say that you were not 
told about these cost share amounts. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copayment for vision care. The enrollees contract with the Plan also clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B drugs. 
 
The enrollee has been asked to pay a $20 copayment for the vision care office visit. This item/service falls 
within the vision care benefit category. The enrollee has also been asked to pay $365.16, which is 20% 
coinsurance of the allowed amount for the drug injection ($1,825.78 allowed amount x 20% coinsurance = 
$365.16). This item/service falls within the Medicare Part B drugs benefit category. The enrollee has been 
asked to pay a total of $385.16 ($20 copayment + $365.16 coinsurance = $385.16). This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the office visit and drug injection provided on July 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation for medical visits by Uber 
(99499). 
 
You asked the Plan to pre-approve routine transportation provided by Uber. You say that you would like 
transportation trips for your medical visits to be provided by Uber. The Plan denied your request. The Plan says 
your benefit only allows travel to a medical appointment for services that are covered by Medicare and your 
Plan. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers unlimited one-way trips to and from plan approved locations provided by ModivCare.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, Uber is not a 
Medicare approved transport company. Therefore, we decided that the Plan does not have to pre-approve 
routine transportation for medical visits by Uber (99499).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion surgery (63052). 
 
You asked the Plan to pre-approve lumbar fusion surgery. 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 lumbar fusion surgery. 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 recent trial of physical therapy for the back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar fusion surgery (63052).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 37244, 36247, 75726, and 
99152. We decided that the Plan does not have to pay for the services described by procedure code(s) 99153.  
 
You asked the Plan to pay for practitioner services provided on January 17, 2023, billed with procedure codes 
99153, 37244, 36247, 75726, and 99152. You say that the claim is billed correctly and should be paid. The 
Plan says that code 99153 is not payable in the facility setting.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 37244, 36247, 75726, 
and 99152.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 37244, 36247, 75726, and 
99152.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE 
only code and that PE are not payable to the physician for services provided in the facility setting.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99153 have not been met.  There is no separate 
payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 99153. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compressor, segmental home model with calibrated 
gradient pressure (E0652) and segmental gradient pressure pneumatic appliance, full leg (E0671). 
 
You asked the Plan to pre-approve a pneumatic compressor and a full leg segmental gradient pressure 
pneumatic appliance. 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 follows Medicare rules. Medicare rules say that pneumatic compression devices are covered when 
specific criteria are met. 
 
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 pneumatic compressor and a full leg 
segmental gradient pressure pneumatic appliance. Our reviewer says that the services are medically necessary. 
Our physician reviewer found the enrollee has lower extremity lymphedema. She has attempted conservative 
treatment with compression garments, diet, elevation, and exercise. The documentation also indicates that the 
enrollee has not responded to a four-week trial of a standard compression device, which is documented with 
measurements. Therefore, the requested segmental compression pump with calibrated gradient pressure 
(E0652) and appliance/accessory (E0671) is 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 a pneumatic compressor and a full leg segmental gradient pressure pneumatic 
appliance have been met. Therefore, we decided that the Plan has to pre-approve a pneumatic compressor, 
segmental home model with calibrated gradient pressure (E0652) and segmental gradient pressure pneumatic 
appliance, full leg (E0671).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair (K0007) provided on January 11, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the wheelchair. You say that this item was medically necessary. The Plan denied 
your request. The Plan says there were network providers available. 
 
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 a wheelchair (K0007) provided on January 11, 
2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 20, 2023, 
through March 21, 2023. 
 You asked the Plan to pay for the home health services. You say that an NOA was successfully submitted on 
January 21, 2023. You state that you attached evidence to support this.  The Plan denied your request. The Plan 
says the NOA was not received timely. The Plan did not receive an NOA until the form attached to the appeal 
request. 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 20, 2023. The NOA was not received by the Plan until May 22, 
2023, along with the appeal request for payment. We reviewed the documents submitted and found that there is 
no evidence proving that an NOA was submitted on January 21, 2023, as is claimed by the provider. 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 provided from 
February 20, 2023, through March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on March 30, 2023, by an OON 
provider.  
 
You asked the Plan to pay for a telehealth visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was 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 a telehealth visit provided on March 30, 2023, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service May 5, 2023.  
 You asked the Plan to pay for procedure code 88291. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88291 is 1. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88291 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88291 billed for date of service May 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) months use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve 3 months use of a home ventilator. You say that the ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the 
requested ventilator. 
 
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. 
 
 
 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 3 months use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does have 
severe COPD with chronic hypoxemic respiratory failure. The enrollee does meet the needs for bilevel positive 
airway pressure (BIPAP) with average volume-assured pressure support (AVAPS) but does not show clear 
evidence of failure of BIPAP to constitute escalation to a home ventilator (Trilogy). Should the enrollee exhibit 
failure of BIPAP with AVAPS then home ventilation would be next best practice step. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 months use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve three (3) months use of a home ventilator (E0466).