Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28470 rendered on April 21, 2023. 
 
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 Current Procedural Terminology (CPT) code 28470 - 54 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 28470 is "Closed treatment of metatarsal fracture; 
without manipulation, each." 
 
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 the 4/21/23 x-rays of the left foot 
have impressions of acute displaced fractures of the distal second, third, and fourth metatarsal bones of the left foot. A short-leg posterior fiberglass splint was applied to the foot. However evidence of ongoing follow up 
fracture care treatment is not clearly evident. Therefore, the documentation does not support that CPT 28470: 
closed treatment of metatarsal fracture, without manipulation was performed in this case. 
 
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 procedure code 28470 rendered on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes G0452, 87481, 
87651, 87653, 87500, 87641, and 87798 for date of service  
 
You asked the Plan to pay for the laboratory services. 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 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 laboratory services billed with codes G0452, 87481, 87651, 87653, 87500, 
87641, and 87798 for date of service
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the CardioMEMS device has not been 
demonstrated in the peer reviewed literature. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 04, 2023. 
 
You asked the Plan to pay for an office visit. You say that the 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 an office visit provided 
on August 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator. 
 
You asked the Plan to pre-approve the Transcutaneous Electrical Nerve Stimulator. You say that this service is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a Transcutaneous Electrical Nerve Stimulator is 
covered for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain. 
 
We looked at the file and Medicare rules. The request for this device is for treatment of sleep apnea. This 
device is not covered for this diagnosis. Based on this information, we decided that Medicare rules for coverage 
of the Transcutaneous Electrical Nerve Stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Transcutaneous Electrical Nerve Stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 11, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the podiatry services. You say that you are requesting reconsideration of the 
denied claim. 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 the podiatry services provided on July 11, 2023, 
by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from July 11, 2023, to 
July 17, 2023.  
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 a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
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 DRG 579. 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 enrollee was treated in the hospital and was diagnosed with a laceration of extensor muscle, fascia and 
tendon of left index finger at wrist and hand which was treated with wound debridement and antibiotics as well 
as simple wound care and pain medication and therapy. The documentation includes description of the lesion 
with possible tenosynovitis. However, the patient was noted to be afebrile, without leukocytosis, and the 
surgical intervention was for the abscess of the tendon area and not the cellulitis. Therefore, the documentation 
does not sufficiently support the diagnosis code L03.012 - cellulitis of left finger - as a primary diagnosis, 
whereas the laceration is more appropriate as the primary diagnosis for this admission. Therefore, the DRG 513 
is more 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 rendered from July 11, 2023, to July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each rest home visit provided on November 
02, 2022, to November 16, 2022. 
 
You asked the Plan to waive the copayment for each rest home visit. You say that the provider is in-network. 
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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for each rest home visit. This item/service falls within the physician/practitioner services, including doctors office visits 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. The total you owe is $80 ($40 copayment x 2 visits 
= $80). Therefore, we decided that the Plan does not have to waive the copayment for each rest home visit 
provided on November 02, 2022, to November 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on July 03, 2023. 
 
You asked the Plan to pay for the mental health services. You say that you are requesting reconsideration of the 
denied claim. 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 mental health 
services provided on July 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cold packs, electrical stimulation, and manual therapy 
techniques provided by a chiropractor on August 28, 2023, and September 7, 2023. 
 
You asked the Plan to pay for cold packs, electrical stimulation, and manual therapy techniques. You say that 
you do not agree with the denial of payment for the services you received. The Plan denied your request. The 
Plan says the maximum allowed for non-Medicare covered services has been met. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
  The records show that the service at issue is not manual manipulation of the spine. Also, the Plan paid up to the 
$500 maximum for chiropractic services. The Plan paid $33.28 on date of service January 9, 2023, $34.60 on 
dates of service February 8, 2023, March 1, 2023, March 8, 2023, and April 17, 2023, $21.58 on date of service 
May 18, 2023, $63.22 on dates of service June 15, 2023, June 22, 2023, July 7, 2023, and July 25, 2023, and 
$53.86 on date of service August 10, 2023. Therefore, the $500 maximum has been met. Therefore, we decided 
that the Plan does not have to pay for cold packs, electrical stimulation, and manual therapy techniques 
provided by a chiropractor on August 28, 2023, and September 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you want to stay for additional therapy because you 
are entitled to 100 days of coverage.  The Plan denied your request. The Plan says you do not meet medical 
necessity criteria for continuation of a Skilled Nursing Facility level of care and have no skilled needs 
currently. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal genetic testing (81479) provided on 
September 7, 2023. 
 
You asked the Plan to pay for a Guardant Reveal test. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says this molecular pathology test is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the DEXTM Diagnostics Exchange does not show that the 
test at issue is covered under the MolDX program. Based on this information, we decided that Medicare rules 
for coverage of a Guardant Reveal test have not been met. Therefore, we decided that the Plan does not have to 
pay for Guardant Reveal genetic testing (81479) provided on September 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tobramycin nebulizer solution. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tobramycin nebulizer 
solution.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pain management services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the pain management services. You say that pain management is only 
giving you relief from your pain with a prescription, which is not the answer. The Plan denied your request. 
The Plan says the enrollee must receive their care from a network provider (for more information about this, 
see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a 
provider who is not part of the plans network) will not be 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 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 
the pain management services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on March 
23, 2023, to March 26, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that this was due to a 
procedure that did not work and had to be repeated. You feel you should not have to pay this. 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 $165 
copayment for inpatient hospital care.  
You have been asked to pay a $165 copayment for an acute inpatient stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $495 for the inpatient hospital stay ($165 copayment 
x 3 days = $495). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for an acute inpatient stay provided on March 23, 2023, to March 
26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 17, 2023, to July 
23, 2023. 
 
You asked the Plan to pay for the home health services. You say that you believe this claim was billed 
correctly. The Plan denied your request. The Plan says this claim was billed with an incorrect Type of Bill 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that he Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).  
Based on this rule, this clam should have been billed with Type of Bill code 0329 or 0327.  Instead, you billed 
with code 0323, which is incorrect. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from July 17, 2023, to July 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 09, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this test was 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 the laboratory services 
provided on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on July 26, 2023. 
 
You asked the Plan to pay for wound care services. You say that this was medically necessary, please review 
and verify. 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 wound care services 
provided on July 26, 2023.