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

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 31, 
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 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service August 15, 2023. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. The Plan denied your request. The 
Plan says these codes are 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 or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service August 15, 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 documents provided support the need for an IRF 
admission. The Plan denied your request. The Plan says the required services can be provided in an alternate 
setting.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies. 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 the enrollee 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 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 skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have appealed before and it keeps getting 
denied. You say it should be covered under the enrollee's insurance. The Plan denied your request. The Plan 
says the enrollee does not meet Medicare guidelines for services in a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not 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. Although 
the enrollee is very limited functionally, the provided records do not document a significant decline in the 
enrollee's functional status, compared to their recent baseline, to necessitate daily inpatient skilled therapy 
services. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. The records support that services in the long-term care facility on a part-
time basis are appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 you need to go to inpatient rehabilitation to get 
stronger so that you can return home faster and be as independent as possible. The Plan denied your request. 
The Plan says you have significantly progressed, and can receive the services you need in a lower level of care.  
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do 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 you 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 13, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99235 rendered on June 24, 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 99235 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 99235 is "Hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
total time on the date of the encounter for code selection, 70 minutes must be met or exceeded." 
 
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 the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level or that at least 
70 minutes were spent. 
 
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 99235 rendered on June 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
October 05, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic test/lab service. 
 
You have been asked to pay a $10 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test/lab service benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an outpatient diagnostic test provided on October 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that D18.01 has an Excludes1 note in relation to D22.9. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on August 10, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for podiatry services. You say that the services were provided in a nursing facility 
and the enrollee was unable to select an in-network provider. The Plan denied your request. The Plan says that 
their original decision to deny payment was correct. 
 
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 podiatry services provided on August 10, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT) and application 
of a modality provided on August 10, 2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment (CMT) and application of a modality. You 
say that this service is supported in the records. 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 chiropractic 
manipulative treatment (CMT) and application of a modality provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat SIJI. 
 
You asked the Plan to pre-approve a repeat SIJI. You say that your pain has returned, and your provider 
recommended a repeat injection. The Plan denied your request. The Plan says the requested procedure does not 
meet the criteria for approval. 
 
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 a repeat SIJI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there is no documentation of at least three positive findings with provocative 
maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, Sacroiliac (SI) Compression, SI Distraction 
and Yeoman Tests. The review has determined that you do not meet the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat SIJI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat SIJI.
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 would benefit from 15 hours of therapy 
per week and requires daily physician oversight to manage medical conditions. The Plan denied your request. 
The Plan says the records show the enrollee's medical conditions are stable, and do not show the need for an 
intensive team for care.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It is not a 
reasonable expectation that the enrollee 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Organ 648 Gene Panel rendered on 
August 25, 2023. 
 
You asked the Plan to pay for the Tempus xT Solid Organ 648 Gene Panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Tempus xT Solid Organ 648 Gene Panel is not 
covered. 
 
We looked at the file and Medicare rules. The testing at issue is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of the Tempus xT Solid Organ 648 Gene Panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT Solid Organ 648 
Gene Panel rendered on August 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump, any type (E0218) 
provided May 23, 2023, to June 13, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says this item is not 
a covered benefit 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump, any type (E0218) provided May 23, 2023, to 
June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 7, 2023, billed with 
procedure code 99202. 
 
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 payment was already made for same/similar 
procedure within set time frame. 
 
The Plan must follow Medicare rules. Medicare rules say interpret the phrase new patient to mean a patient 
who has not received any professional services, i.e., evaluation and management (EM) service or other face-to-face service from the physician group practice within the previous 3 years. 
 
We looked at 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 August 7, 2023, billed with procedure code 99202.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that your scooter is down and making clunking 
noises. The Plan denied your request. The Plan says the records show you have a Group 2 power wheelchair 
and therefore a power scooter is not necessary. 
 
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 have a Group 2 power wheelchair. A Group 2 power wheelchair serves the same purpose as a power scooter. Therefore, we decided that the Plan does not have to pre-approve a power scooter 
(K0800).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
29, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery/ambulatory surgical center. 
 
You have been asked to pay a $200 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/ambulatory surgical center 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 $190.59. Therefore, we decided that the Plan does not have to waive the copayment for an 
outpatient surgery provided on March 29, 2023.