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

 
We decided that the Plan does not have to pre-approve a portable ramp (E1399). 
 
You asked the Plan to pre-approve a portable ramp. You say that you need the portable ramp because your 
scooter is too heavy.  The Plan denied your request. The Plan says portable ramps are not covered because they 
are a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a portable ramp (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided on 
December 01, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you did not know 
the copayment would apply to telehealth services. 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 $35 
copayment for specialist telehealth physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist telehealth visit. This item/service falls within 
the specialist telehealth 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 EOC shows that the copayment applies to telehealth 
services. Therefore, we decided that the Plan does not have to waive the copayment for the specialist telehealth 
visit provided on December 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94060, 94726, and 94729 billed for date of 
service July 22, 2022. 
 You asked the Plan to pay for procedure codes 94060, 94726, and 94729. You say that the modifier is 
compatible with the billed code. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 94060, 94726, and 94729. This means 
there is both a professional and technical component for the CPT codes. In this case, an appropriate modifier to 
indicate the professional component has not been billed with the CPT codes. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 94060, 94726, and 94729 billed for date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine exam  
(code 99397) provided on December 16, 2021. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine exam. You say that you should 
be covered based on previous coverage when you got the exam every other year. The Plan denied your request. 
The Plan says you exceeded the maximum yearly benefit. The benefit was previously applied on  
claim # 820211261344025 for date of service April 15, 2021, for procedure codes 99397 and G0439. 
 
The Plan contract says that the Plan covers a comprehensive preventive medicine evaluation once per year. 
 
We looked at the file and the Plans rules. The file shows that you have exceed the maximum benefit limit. 
Based on this information, we decided that the Plans rules for coverage of the periodic comprehensive 
preventive medicine exam have not been met. Therefore, we decided that the Plan does not have to pay for a 
periodic comprehensive preventive medicine exam (code 99397) provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 99072, and 94761 billed for date of 
service December 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported for code 87631. We 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 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 as it was billed with other payable services. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87631, 99072, and 94761 billed for date of service December 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 2, 2022, to May 1, 
2022. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
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 start of care date is March 3, 2022. The NOA was not received by the Plan until September 15, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, 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 April 2, 2022, to May 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this code is not bundled with any other 
codes billed on this date of service. You say that the documentation supports the service for separate 
reimbursement and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 27, 2023.  
 
You asked the Plan to pay for the testing services. You say that the test provides clinical guidance to better 
service the enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that the comprehensive gene panel was not billed with a single code as required. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing billed for date of service February 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hospitalization program. 
 
You asked the Plan to pre-approve partial hospitalization program. You say that the enrollee symptoms require 
to be treated in a partial hospitalization program. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for a partial hospitalization program. 
 
The Plan follows Medicare rules. Medicare rules state that partial hospitalization programs (PHPs) are only 
covered for certain qualifying Medicare beneficiaries. 
 
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 partial hospitalization program. Our 
reviewer says that the enrollee does not meet criteria for a partial hospitalization program. Our physician 
reviewer found the enrollee is not showing any dangerousness to self or others and has not been exhibiting any 
current psychological or psychiatric impairment. The enrollee has not been showing any moderate dysfunction 
in family, social environment or performance of daily living skills. The enrollee was not showing any 
dangerousness to self or others and not showing any perceptual disturbance, psychosis or aggressive behaviors. 
It does not appear medically necessary and reasonable to have psychiatric care provided at the partial 
hospitalization level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial hospitalization program have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a partial hospitalization program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom 6 continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve the Dexcom 6 continuous glucose monitor (CGM) and supplies. You say 
that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pre-approve the Dexcom 6 continuous glucose 
monitor (CGM) and supplies. Our reviewer says that the enrollee does not need these items. Our physician 
reviewer found the enrollee is not using insulin and is not have low blood sugar. 
 
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 Dexcom 6 continuous glucose monitor (CGM) and supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom 6 continuous glucose 
monitor (CGM) and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27599 for date of service January 4, 2023. 
 
You asked the Plan to pay for procedure code 27599. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that specific codes are payable when provided in an 
ambulatory surgical center. 
 
 We looked at the file and Medicare rules. Procedure code 27599 is not listed in the ambulatory surgical center 
covered surgical procedures for calendar year 2023. This means code 27599 is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of procedure code 27599 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 27599 for date of service January 
4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says the imaging studies support fracture retropulsion and canal compromise which are 
contraindications for this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet coverage criteria. Our physician reviewer found the noted compression fracture at L2 is 
not an acute and/or subacute fracture. Moreover, the magnetic resonance imaging does indicate retropulsion at 
L2, a contraindication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from rehab to optimize their 
level of function before returning home. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an IRF.  
 
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 pre-approve 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 medical record supports a need for physical or occupational therapy. The 
documentation does not show that the enrollee would require an intensive rehabilitation regimen. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service October 24, 
2022.  
 
You asked the Plan to pay for procedure code 64488. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
We find that code 64488 is a bilateral code. In this case, the MUE for CPT code 64488 is 1. The MAI value for 
this code is 3. You billed 2 units of this code, exceeding the MUE. The documentation did not show that the 
excess units were provided, correctly coded, and medically necessary. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 64488 billed for date of service October 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Marriage and Family Therapist (LMFT) from January 3, 2023, to January 30, 2023. 
 
You asked the Plan to pay for the LMFT services. You say that prior to turning 65, your employer's coverage 
reimbursed you for services with this LMFT. You said that you were told that your new insurance would be the 
same. The Plan denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. 
 
In this case, you received the services at issue from a LMFT.  A LMFT is not a valid provider for Medicare, so 
these services cannot be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMFT services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services you received from a Licensed Marriage and Family Therapist (LMFT) from 
January 3, 2023, to January 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from rehab to optimize their 
level of functioning prior to returning home. The Plan denied your request. The Plan says the services the 
enrollee needs can be provided safely in another setting such as a skilled nursing facility, home with home 
health services or home with outpatient therapy.  
 
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 pre-approve 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 enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of SNF care. 
 You asked the Plan to pre-approve the continuation of SNF care. You say that it is unsafe for the enrollee to be 
discharged from the SNF. The Plan denied your request. The Plan says  the enrollee does not require daily 
skilled nursing or rehabilitation services. 
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The 
enrollees care needs can, as a practical matter, be provided at a lower level of care. 
 
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 the continuation of SNF care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a Mental 
Health Counselor (MHC) from January 11, 2023, to February 15, 2023. 
 
You asked the Plan to pay for the MHC services. You say that services with this provider were covered in 
previous years. The Plan denied your request. The Plan says services with this type of provider are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. 
 
In this case, you received services from a MHC.  A MHC is not a valid provider type for Medicare, so these 
services cannot be covered.  This is true regardless of whether or not services with this provider had been 
covered in previous years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MHC services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services you received from a Mental Health Counselor (MHC) from January 11, 2023, 
to February 15, 2023.