Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from AUGUST 11, 2023, through AUGUST 27, 2023. 
 
You asked the Plan to pay for the IRF care. You say that The enrollee's rep says the IRF admission provided 
from August 11, 2023, to August 27, 2023 was medically necessary. 
 
 
 
 
  
 
 
 
 
 
 
-Appeal Letter: Pages 26-28 The Plan denied your request. The Plan says The Plan says the IRF admission 
does not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for lumbar and thoracic compression fractures after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from AUGUST 11, 
2023, through AUGUST 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 25, 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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 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 claim does not show that the required unique identifier 
was reported. 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 laboratory services rendered on 
September 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on August 
31, 2023. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. You say that you do not understand why 
the Plan did not pay for some of the procedure. 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 $275 
copayment for outpatient surgery and other medical services provided at ambulatory surgical centers. 
 
You have been asked to pay a $275 copayment for the cystourethroscopy. This item/service falls within the outpatient surgery and other medical services provided at ambulatory surgical centers 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, since the 
allowed amount is less than the standard copayment, you only owe $272.82. Therefore, we decided that the 
Plan does not have to waive the copayment for the cystourethroscopy provided on August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 22, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 13, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 16, 
2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307. 
 
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 83789 
is a column II code to column I code 80307. The -59 modifier is not supported as a separate and distinct 
procedural service. 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 83789 billed for date of service August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
August 30, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be 
obligated to pay for this follow-up visit. 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 $30 
copayment for physician/practitioner services. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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. The record shows this specialist office visit was rendered outside the global 
surgery billing period. Therefore, we decided that the Plan does not have to waive the copayment for the 
specialist office visit provided on August 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incontinence supplies (A4554, A4520, and A9286) 
provided on August 15, 2023. 
 
You asked the Plan to pay for the incontinence supplies. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the items are not covered by Medicare or 
the Plan.  
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. Medicare rules also say that disposable underpads 
(A4554) and incontinent garments (A4520) are not covered. 
 
The requested items (A4554, A4520, and A9286) are to be used as incontinence supplies. While incontinence 
supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. 
Therefore, we decided that the Plan does not have to pay for the incontinence supplies (A4554, A4520, and 
A9286) provided on August 15, 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 admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet all the requirements for LTACH admission. The Plan says services may be provided at a lower level of care.

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 enrollee does not require ventilator weaning, does not have complex wound care needs (daily dressing changes), and does not meet LTACH admission criteria.

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: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a screening colonoscopy provided on January 12, 
2023. 
 
You asked the Plan to waive the copayment for a screening colonoscopy. You say that this should be a 
screening colonoscopy and should not have a copayment. The Plan denied your request. The Plan says that 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 enrollees must pay a $0 copayment for colorectal cancer screening.  
 
The Plan says you must pay a $275 copayment for an outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers. Based on the Plan contract, however, you cannot 
be asked to pay more than a $0 copayment for a screening colonoscopy. Therefore, we decided that the Plan 
has to waive the copayment for a screening colonoscopy provided on January 12, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01922 performed 
on date of service July 10, 2023. 
 
You asked the Plan to pay for 01922. You say that 01922 should be paid as billed because it is supported in the 
medical record, and you are dependent on the facility to obtain any necessary referrals or prior authorizations. 
The Plan denied your request. The Plan says 01922 is denied because it was billed on the same date of service 
as 01924 without a modifier to distinguish between the two encounters. 
 The Plan must follow Medicare rules. Medicare rules say that payment for anesthesia services associated with 
multiple surgical procedures is determined based on the base unit of the anesthesia procedure with the highest 
base unit value and time units based on the actual anesthesia time of the multiple procedures. 
 
We looked at the file and Medicare rules. In this case we confirmed that 01922 and 01924 were billed on the 
same date of service by providers of the same specialty and group practice, which is considered the same 
provider. We confirmed that a modifier -51 was not appended to either code. Payment for anesthesia associated 
with multiple procedures is determined based on the base unit of the anesthesia procedure with the highest base 
unit value and actual anesthesia time for the multiple procedures. Providers should report the total time for all 
procedures in the line item with the highest base unit value. Based on this information, we decided that 
Medicare rules for coverage of 01922 have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services described by code 01922 performed on date of service July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
13, 2023.  
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing 
facility care provided on September 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61645 rendered on September 3, 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 61645 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 61645 is ""Percutaneous arterial transluminal mechanical 
thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, 
fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s)." 
 
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 CPT code 61645 indicates 
endovascular (catheter-based) revascularization of an intracranial artery. The documentation provided does not 
include an operative/procedural report describing the procedure performed. 
 
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 61645 rendered on September 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81226, 81227, 81240, 81241, & 81328) 
provided on April 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 lab services (81226, 81227, 81240, 81241, & 81328) provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 91065 billed for date of service October 11, 
2023.  
 You asked the Plan to pay for procedure code 91065. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 91065 is 2. The MAI value for this code is 2. You billed 6 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 91065 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 91065 billed for date of service October 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on October 06, 2023. 
 
You asked the Plan to pay for a facility visit. You say that the enrollee is in a facility and the facility should 
have obtained the prior authorization. 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 a facility visit provided 
on October 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on October 
02, 2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. 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 chiropractic 
manipulative treatment provided on October 02, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 22, 2022, 
to December 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you were not aware of the Plan's 
rule change with regard to NOAs. 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 November 22, 2022, to 
December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 21, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services provided 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 subsequent nursing 
facility care provided on August 21, 2023.