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

 
We decided that the Plan does not have to pre-approve sixty (60) home health aide (HHA) visits (G0156). 
 
You asked the Plan to pre-approve the aide services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 
 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found medical notes from 
your treating physician are provided documenting an order or need for skilled home health nursing, therapy or 
home health aide services. Provided records do not document any acute or unstable medical conditions or 
changes in medication or treatment which would necessitate any further skilled nursing or therapy services. 
Records do not document the need for intravenous medications, new tube feeding or ostomy care or complex 
wound care. As skilled home health nursing and therapy services are not being provided, home health aide 
services are not covered by Medicare. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sixty (60) home health aide (HHA) visits (G0156).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 17, 2022, to 
August 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA has been 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 17, 2022, to August 
15, 2022.  
 
Please note that this decision is limited to the Plans denial of your initial claim.  Any questions regarding the 
submission of a corrected claim need to be sent to the Plan directly.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 17, 2022, to 
April 15, 2022. 
 You asked the Plan to pay for the home health services. You say that you sent in the NOA on March 18, 2022. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied. The Plan states that although you contend that the NOA was submitted, none has been received by the 
Plan. 
 
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 NOA was not received by the Plan. As a result, 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 March 17, 
2022, to April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a Life2000 ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says this ventilator is not medically necessary. 
 
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 ventilator. Our reviewer says that the 
enrollee does not meet criteria for a ventilator. Our physician reviewer found the records show that the ventilator is being requested for use with very low set tidal volumes which could be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) mode and a 
back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of a Life2000 ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) equipment provided on March 07, 2023, to April 07, 2023. 
 
You asked the Plan to waive the coinsurance for the continuous positive airway pressure (CPAP) equipment. 
You say that you were told you would not have to pay for this equipment. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous positive airway pressure (CPAP) equipment. 
This item/service falls within the durable medical equipment and related supplies 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 $16.60 ($83 
allowed amount x 20% coinsurance = $16.60). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the continuous positive airway pressure (CPAP) equipment provided on March 07, 2023, to 
April 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service February 10, 
2023. 
 
You asked the Plan to pay for procedure code S9083. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on February 9, 
2023. 
 
You asked the Plan to waive the deductible for an office visit. You say that this claim should be reprocessed at 
the in-network benefit level. The Plan denied your request. The Plan says this cost sharing was charged 
correctly.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network 
physician/practitioner services, including doctor's office visits.  
 
The enrollee has been asked to pay $94.83 towards the deductible for the office visit. The item or service you 
asked the Plan to waive the deductible for falls within the physician/practitioner services, including doctor's 
office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $1,000 deductible which applies to physician/practitioner services, including doctor's office visits. 
This cost sharing is a contractual obligation that had not been met at the time an office visit was received on 
February 9, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an office visit 
provided on February 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on March 06, 2023. 
 
You asked the Plan to waive the copayment for x-ray services. 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 $110 
copayment for outpatient diagnostic tests/basic radiological services. 
 
You have been asked to pay a $110 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/basic radiological services 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. However, you are only being asked to pay $85.43 which is less than the required amount. Therefore, we decided that the Plan does not have to waive the copayment for x-ray services 
provided on March 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH level of 
care and is stable for discharge. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service November 
27, 2022. 
 
You asked the Plan to pay for procedure code S9083. You say that the claim denied incorrectly. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service November 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 08, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $40 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 10, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan injections. 
 
You asked the Plan to pre-approve the Hyalgan injections. You say that the enrollee has failed 3-months of 
conservative treatment. The Plan denied your request. The Plan says the enrollee has not tried and completed 
physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Hyalgan injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation states that on 
May 25, 2023, the enrollee stated that they had relief from conservative therapy and wanted to wait on getting 
the knee injections. There is no documentation provided indicating that the enrollee has failed at least 3-months 
of conservative therapy. The review has determined that the documentation does not support that Hyalgan is 
medically reasonable or necessary for the 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 the Hyalgan injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyalgan injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99213 and 29550 billed for date of service 
March 30, 2023. 
 You asked the Plan to pay for the billed services. You say that the services should be paid separately. The Plan 
denied your request. The Plan says the services were not billed appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99213 was billed with diagnosis codes M71.572 and M20.12. Diagnosis code group 
M71 has an Excludes1 note which includes diagnosis code group M20.1. This means the codes should never be 
used at the same time.  
 
The CPT Code Manual definition of code 29550 is strapping; toes. We find that code 29550 was not billed with 
an anatomic modifier to indicate which toes were treated. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99213 and 29550 billed for date of service March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient diagnostic tests provided on 
February 27, 2023. 
 
You asked the Plan to waive the coinsurance for an outpatient diagnostic tests. You say that you disagree with 
the coinsurance. 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 20% 
coinsurance for outpatient diagnostic tests/other outpatient diagnostic tests. 
 
You have been asked to pay 20% coinsurance for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/other outpatient diagnostic tests 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 allowed amount for the outpatient 
diagnostic tests is $1,081.49. You are being asked to pay $216.30 ($1,081.49 x 20% = $216.30). Therefore, we 
decided that the Plan does not have to waive the coinsurance for an outpatient diagnostic tests provided on 
February 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 4, 2022, to April 
2, 2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA was provided. The Plan 
denied your request. The Plan says the NOA was not received. As such, this final claim was correctly denied. 
The Plan says that although your appeal contends that the NOA was submitted, none has been received. 
 
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 NOA was not received by the Plan. As a result, 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 March 4, 
2022, to April 2, 2022.
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 the enrollee was initially approved but was not 
stable to admit at the time. The Plan denied your request. The Plan says the SNF services you are requesting do 
not meet the requirements for approval. 
 
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 require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services on an inpatient basis 
in a 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous allergy skin tests (95004 x80). 
 
You asked the Plan to pre-approve percutaneous allergy skin tests. You say that you were told it was your 
responsibility to appeal. You also say that you have an epinephrine pen (EpiPen) but keep having a rash like 
welt breakout which was the purpose of getting a prior authorization. The Plan denied your request. The Plan 
says you do not meet the criteria for coverage. 
 
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 percutaneous allergy skin tests. 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 of inadequate control of symptomatology with 
conservative therapy. Our reviewer also found that there is no indication of inadequate benefit from consistent 
concurrent use of both an oral antihistamine and a nasal corticosteroid. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous allergy skin tests have not been met. Therefore, we decided that 
the Plan does not have to pre-approve percutaneous allergy skin tests (95004 x80).