Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 22, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4239 is considered bundled and not separately 
payable.  
 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 A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service March 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery and ocular photography provided on 
September 26, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for cataract surgery and ocular photography. You say that this should be covered. 
The Plan denied your request. The Plan says this 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 cataract surgery and ocular photography provided 
on September 26, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider is out of the network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that the plan is not required to provide access to home 
visits from a nurse practitioner who is not in-network. The enrollee has standard access to their primary care 
practitioner. 
 
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 services have not been met.  
 
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 the services. Therefore, we decided that the Plan does 
not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the grab bars provided on February 18, 2023. 
 
You asked the Plan to reimburse you for the grab bars. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says no proof of payment has been provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the grab bars have been met. In this 
case, the file shows that you provided an invoice instead of a receipt. Invoices are issued prior to the customer 
sending payments, whereas a receipt is issued after the payment has been made. Your contract with the Plan 
clearly states to send your bill and documentation of any payment you have made. Therefore, we decided that 
the Plan does not have to reimburse you for the grab bars provided on February 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services provided on January 23, 
2023. 
 
You asked the Plan to pay for the surgery. The Plan denied your request. The Plan says you submitted the 
claim on an incorrect type of bill.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit claims with the correct 
TOB code. 
 
In this case, your claim was submitted with TOB code 0130. The definition of 0 as the fourth digit is Nonpayment/Zero Claims. It indicates the provider does not anticipate payment from the payer. It only informs 
the payer about a period of non-payable confinement or termination of care. Your claim cannot be paid as 
billed. Based on this information, we decided that Medicare rules for coverage of the surgery have not been 
met. Therefore, we decided that the Plan does not have to pay for the outpatient surgical services provided on 
January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the documentation submitted fails to indicate that you are requiring the non-
invasive ventilator (NIV) for use in other than bilevel positive airway pressure (BiPAP) or BiPAP with average 
volume-assured pressure support (AVAPS) mode. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The record indicates that the enrollee is being treated with a device in the BiPAP-AVAPS mode. The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability 
and failure of such a device has not been documented.  The elements of the coverage criteria are not satisfied. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services billed with codes 72040, 70100, 71045, 
70310, 74230, and 74240 for June 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed with the correct place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an 
office; however, the file shows that the services were performed in a mobile unit at a skilled nursing facility. Therefore, we decided that the Plan does not have to pay for the x-ray services billed with codes 72040, 70100, 
71045, 70310, 74230, and 74240 for June 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from January 6, 2023, 
to February 16, 2023. 
 
You asked the Plan to waive the copayment for a SNF visit. You say that you were advised the facility was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $250 copayment per day for OON SNF care.  
 
 
  The enrollee has been asked to pay a $10,500 copayment for an OON SNF visit ($250 per day x 42 days). This 
item/service falls within the SNF care benefit category. 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 
copayment for a SNF visit provided from January 6, 2023, to February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on March 7, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is not covered. The Plan 
denied your request. The Plan says this testing is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient insulin treatment provided on March 23, 2023.  
 
You asked the Plan to pay for the insulin treatment. You say that this was medically necessary.  The Plan 
denied your request. The Plan says this is noncovered by Medicare and was not billed correctly.  
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is nationally noncovered by Medicare.  
Therefore, we decided that the Plan does not have to pay for the outpatient insulin treatment provided on March 
23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary,  
The Plan denied your request. The Plan says the enrollee is receiving the care they need in the hospital where 
they are now and there is no need to transfer to the LTACH at this time. 
 
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 the record indicates that the enrollee has ongoing acute care issues and still requires 
acute care services. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that they are not currently receiving but that 
would be available at the LTACH 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 long term acute care hospital (LTACH) services.
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 is currently stable to 
discharge to LTACH level of care for respiratory weaning and medical management. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary, and the enrollee can safely receive the 
services they need in the current hospital setting.  
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 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 Practitioner services provided on March 23, 2023, billed with 
procedure codes 96365-59, 96366-59 x2, 96521, and J1817. 
 
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 96365-59, 96366-59 x2, 96521, and J1817 is 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure), Refilling and maintenance of portable pump, and 
Insulin for administration through durable medical equipment (i.e., insulin pump) per 50 units.  
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 medical records provided does 
not include sufficient documentation to validate that 96365 and 96366 are the most appropriate codes to use for 
the services performed. The Medical records provided does include an order to perform refilling and 
maintenance of a portable pump, however, the medical records also indicate that outpatient intravenous insulin 
treatment (OIVIT) was performed but does not include a procedure report for pump maintenance refill, 
therefore procedure code 96521 cannot be verified. The medical records provided does not include sufficient 
documentation to validate that Insulin for administration through Durable medical equipment (i.e., insulin 
pump) per 50 units was performed on March 23, 2023, therefore, this procedure 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 March 23, 2023, billed with procedure 
codes 96365-59, 96366-59 x2, 96521, and J1817.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 24, 2022, to 
June 28, 2022, 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 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 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 A41.9, described as Sepsis, 
unspecified organism. 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 documentation does not support the billed code. 
Our physician reviewer found that the enrollee presented with transient abdominal pain, and dizziness with 
nausea/vomiting. She appears to have been diagnosed with gallbladder sludge/cholecystitis and her usual 
Menieres disease. There is no evidence of hypotension, hypoperfusion or organ failure. As such, a diagnosis of 
sepsis 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 June 24, 2022, to June 28, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide. 
 
You asked the Plan to pre-approve the aide services. You say that this is medically necessary. The Plan denied 
your request. The Plan says a home health aide is not a covered benefit. 
 
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 that the enrollee is noted to have Alzheimers Dementia with cognitive impairment. The enrollee requires assistance for his daily 
activities and supervision. The assistance required does not necessitate the services of a skilled nurse or 
therapist and can be provided by a personal care assistant. The enrollee does not require skilled nursing care in 
the home, and he is already receiving physical therapy. Therefore, the home health services are not 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 the aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home health aide.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the intensity modulated radiation therapy (IMRT) billed with code 
77427 for January 6, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that code 77427 should only be reported after the fifth treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that code 77427 can only be reported after the fifth treatment has 
been performed and cites Local Coverage Determination (LCD) L34652. This LCD was retired on the date of 
service at issue and is also not the correct jurisdiction for Part B Medicare for the state of Texas, where the 
services were performed. The Plan has not provided any documentation or binding Medicare rules to support 
that the IMRT is not payable as billed. Therefore, we decided that the Plan has to pay for the intensity 
modulated radiation therapy (IMRT) billed with code 77427 for January 6, 2023.  
 
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.