Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from August 12, 2022, to 
November 17, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that you sought services with this provider 
because you share the same religious values and that she is a geriatric psychiatrist. The Plan denied your 
request. The Plan says you received services from a provider who chose not to receive Medicare funds.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program.  Therefore, we decided that the Plan does not have to pay for 
psychotherapy services provided from August 12, 2022, to November 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services for speech and physical 
therapy. 
 You asked the Plan to pre-approve home health services. You say that you need speech and physical therapy to 
get you stronger. You state that you have not been out of the house for six (6) months. The Plan denied your 
request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the Health 
Plans denial should be upheld. You do not have documented, intermittent, skilled, home health needs. As 
such, the requested home health services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health services for speech and physical therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87631), noninvasive ear or pulse 
oximetry for oxygen saturation (94761) and additional supplies (99072) provided on October 31, 2022. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
For the laboratory testing (87631), for molecular diagnostic tests and other molecular pathology services 
administered through the Molecular Diagnostic Services (MolDX) Program, Medicare requires laboratories to 
apply for and obtain a test-specific identifier (a DEX Z-Code) that is unique to the laboratory's specific test. 
This identifier must be submitted as additional information at the time of claim submission and must be 
reported in conjunction with the appropriate Current Procedural Terminology (CPT)/Healthcare Common 
Procedure Coding System (HCPCS) code. Therefore, a DEX-Z code was not submitted on the claim. 
 
Furthermore, we find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. This 
means that procedure code 94761 is not separately payable because there are relative value units (RVUs) and 
payment amounts for these services, but they are only paid if there are no other services payable under the 
physician fee schedule billed on the same date by the same provider. If any other services payable under the 
physician fee schedule are billed on the same date by the same provider, these services are bundled into the 
physician services for which payment is made. 
 
We also find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99072 is not separately payable.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory service (87631), noninvasive ear or pulse oximetry for oxygen saturation (94761) and 
additional supplies (99072) provided on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient hospital clinic visit provided on November 15, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient hospital clinic visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says 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 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 pay for the outpatient hospital clinic visit. Our reviewer says that the records do not 
indicate that the care provided was medically necessary. Our physician reviewer found the enrollee was treated 
at an out-of-network clinic visit for a stye on left eye for prior 3-4 days and a sore on the left nostril. While the 
enrollee could not have foreseen requiring the services prior to leaving his service area, it would have been 
medically reasonable to delay the services which were not emergent. 
 
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 outpatient hospital clinic visit 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 pay for the outpatient hospital clinic visit. Therefore, we decided 
that the Plan does not have to pay for an outpatient hospital clinic visit provided on November 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on June 10, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the imaging services rendered on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 9, 2021, to 
February 18, 2021, 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 was 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 code 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 the enrollee is a 78-year-old female who was treated in the hospital. She 
presented with tachycardia, hypotension, and normal oxygenation on room air. She was diagnosed with urinary 
tract infection based on urinalysis and pneumonia based on chest X-ray and mild leukocytosis and started on 
antibiotics and fluids. Adenosine was also given for tachycardia. The documentation also described the 
enrollee's blood pressure rising to normal with fluids. She was alert and oriented, had normal platelets, 
creatinine, and bilirubin levels. There was insufficient evidence of a dysregulated response to the infection 
leading to organ failure as required by the Sepsis 3 criteria. Therefore, the documentation did not sufficiently 
support the code, A41.9, sepsis.   
 
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 February 9, 2021, to February 18, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the ankle-foot orthosis (AFO), plastic with ankle joint, custom 
fabricated (L1970). 
 
You asked the Plan to pre-approve the orthosis. You say that  the enrollee's condition has progressed, resulting 
in the need for a new brace. The Plan denied your request. The Plan says that the enrollee received a custom 
brace on February 26, 2020. The Plan states the provider does not mention why a repair or adjustment of 
current brace cannot be performed.  
 
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 orthosis. Our physician reviewer 
found the requested new custom AFO is medically reasonable and necessary. Medicare guidelines advise that 
they will pay for items or services that are medically reasonable and necessary for the treatment of a patients 
illness or injury. These devices must be not mainly for the convenience of the patient or the physician, 
appropriate, and standard of care. In this particular case, the enrollee is noted to have stage II posterior tibial 
tendon dysfunction with a significant rear foot valgus and prominent talus head medially. The progress note also advises that the pathology has progressed over time, making the enrollee's current custom AFO non-
supportive and irritative. The physician has recommended a new custom AFO to accommodate the changing 
pathology of the enrollee's right foot and ankle. Therefore, the requested new custom AFO is medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the orthosis have been met. Therefore, we decided that the Plan has to pre-
approve the ankle-foot orthosis (AFO), plastic with ankle joint, custom fabricated (L1970).  
 
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 the vision services billed with codes V2627, V2628, and 
V2629 for June 30, 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 correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that the codes at issue were not correctly billed with the required anatomical modifiers. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the vision 
services billed with codes V2627, V2628, and V2629 for June 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the critical care, evaluation and management of the critically ill or 
critically injured patient for the first 3074 minutes (99291) provided on November 12, 2022. 
 
You asked the Plan to pay for the service. You say that the enrollee had multiple exams on the same date of 
service. The Plan denied your request. The Plan says that a single physician cannot bill multiple units of CPT 
99291 per date of service. 
 
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 documentation provided from the Plan does not show that the Plan paid the 
provider for any exam provided. Therefore, we do not know if the service was paid to validate the Plan 
correctly denied payment for 99291 provided on November 12, 2022. Therefore, we decided that the Plan has 
to pay for the critical care, evaluation and management of the critically ill or critically injured patient for the 
first 3074 minutes (99291) provided on November 12, 2022.  
 
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 pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic obstructive pulmonary disease (COPD) with obstructive sleep apnea and chronic hypercarbic respiratory 
failure. An arterial blood gas (ABG) on March 30, 2023 was consistent with hypercarbic respiratory failure. 
The ventilator is being requested for intelligent volume assured pressure support (IVAPS-AE). Medicare does 
not cover the ventilator for this use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the request is based on travel 
time and carrying the oxygen tank which is very difficult at times. You also say you must stop in the parking 
lot several times before you can get to your appointments. The Plan denied your request. The Plan says there is 
no indication your current oxygen equipment is not meeting your medical needs or ADLs in or around the 
home. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you were approved for a home-fill portable oxygen system on February 22, 2023. This 
equipment serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service November 7, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 36000 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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 
16, 2022. 
 You asked the Plan to pay for procedure code 87481. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 87481 is bundled into payment for code 87801. 
 
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, we have confirmed that code 87481 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 16, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment billed with code G2067 for 
January 17, 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 the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
billed with code G2067 for January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex 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 unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 this device is experimental for back pain. More research is needed. 
 
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 Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 29, 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 testing that will not diagnose or treat an illness is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Know Error DNA Specimen Provenance Assay, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on February 23, 2023. 
 
You asked the Plan to pay for nurse practitioner services. You say that the services were medically necessary. 
The Plan denied your request. 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 Plan says that the Plan 
has also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on February 23, 2023.