Persius/hicric huggingface dataset:
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 need the care at a SNF. You also say without 
the coverage, your health and well-being will decline. The Plan denied your request. The Plan says  the SNF 
services requested do not meet the requirements for approval. 
 
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 there are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 this care to regain function and return to 
prior living situation. The Plan denied your request. The Plan says medical records do not support the need for 
an IRF admission and, your needs can be safely provided at another 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 your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for magnetic resonance imaging (MRI) of the brain (70551) and MRI of 
the cervical spine (72141) provided on December 7, 2022. 
 
You asked the Plan to pay for the MRIs. You say that you were unaware you would be receiving a bill because 
it was pre-approved and paid. The Plan denied your request. The Plan says that an Explanation of Benefits 
(EOB) is needed before this claim can be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for magnetic resonance imaging (MRI) of the brain (70551) and 
MRI of the cervical spine (72141) provided on December 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2023 to September 9, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2023 to September 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit received on July 24, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the new patient office visit. You say that you felt it imperative to acquire a 
second opinion regarding the removal of a cataract due to the problem that you had with the removal of their 
first cataract. The Plan denied your request. The Plan says an authorization must be obtained by you or the 
provider before the services are received. 
 
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 the new patient office visit received on July 24, 
2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44005 and 99232 provided on June 5, 2023 
to June 21, 2023.  
You asked the Plan to pay for procedure codes 44005 and 99232. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the codes billed are not separately payable 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
The rules also say that if a provider reports two codes of an edit pair, only the Column One code is payable. For 
edits with a modifier indicator of 0, the Column Two code cannot be paid regardless of whether a modifier is 
used. 
 
We looked at the file and Medicare rules. Procedure code 99232 was provided within the global surgery period 
of code 44120. We find that the service at issue may be unrelated to the surgical procedure; however, the 
required modifier to indicate this was not used. Procedure code 44005 is a column II code to column I code 
44120. There is a modifier indicator of 0, so the edit cannot be bypassed. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
44005 and 99232 provided on June 5, 2023 to June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851) provided on July 17, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no documentation of knee instability, injury, or surgery. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee had not had recent surgery or a recent injury.  The documentation doesnt 
support that the joint was unstable or that there was joint laxity. The requested knee orthosis for 7/17/2023 is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1851) provided on July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service September 
13, 2023.  
 
You asked the Plan to pay for procedure code 88377. 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.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service September 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
September 18, 2023, to September 19, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for the emergency room visit. This item/service falls within the 
emergency care 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 the emergency room visit 
provided on September 18, 2023, to September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and provided on August 10, 2023. 
 
You asked the Plan to pay for the office visit (99214) and. You say that no referral is required per the enrollees 
online eligibility. 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 office visit (99214) 
and provided on August 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 
28, 2023.  
 
You asked the Plan to pay for procedure code 99233. You say that the service was billed correct and should be 
paid. The Plan denied your request. The Plan says payment for code 99233 is bundled into payment for code 
99156. 
 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 99233 
is a column two code to column one code 99156 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 99233 billed for date of service September 28, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional trips, routine transportation. 
 
You asked the Plan to pre-approve routine transportation. The Plan denied your request. The Plan says the 
transportation benefit only allows 48 trips for this service additional transportation will exceed the benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 36 additional trips, routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6222 billed for date of service November 8, 
2022. 
 
You asked the Plan to pay for procedure code A6222. The Plan denied your request. The Plan says procedure 
code A6222 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 A6222 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6222 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A6222 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6222 billed for date of service November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on June 15, 2023. 
 
You asked the Plan to pay for a walker. You say that the supplies should be covered. 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 walker provided on 
June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q4188 rendered on July 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 Healthcare Common Procedure Coding System (HCPCS) code Q4188 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 Q4188 is "Amnioarmor, per square centimeter." 
 
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 Q4188 is not supported. The record 
does not specify the type of allograft applied. There are multiple types of skin allografts with different CPT 
codes. It cannot be verified that Q4188 is correct.  
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 Q4188 rendered on July 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation. 
 
You asked the Plan to pre-approve sacral nerve stimulation. You say that the request is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is not covered. The Plan follows Medicare rules. Medicare rules say that patients with stress incontinence, urinary obstruction, 
and specific neurologic diseases which are associated with secondary manifestations of the above three 
indications are excluded. 
 
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 sacral nerve stimulation. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found the records 
document the enrollee's urinary incontinence is likely neurogenic in nature given their prior history of an 
astrocytoma and craniotomy. The National Coverage Determination (NCD) states that urinary incontinence due 
to a neurological disease is excluded from coverage for the sacral nerve stimulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacral nerve stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacral nerve stimulation.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70450 provided on September 16, 2023. 
 
You asked the Plan to pay for procedure code 70450. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says that the procedure code is bundled 
to another service billed on the same day. 
 
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. We find that the Plan did not submit the documentation to support that procedure 
code 70496 was billed on the same day, by the same provider or specialty group. Without the required 
documentation, procedure code 70450 is not considered bundled for payment. Therefore, we decided that the 
Plan has to pay for procedure code 70450 provided on September 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided June 1, 2023. 
 
You asked the Plan to pay for the laboratory 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 CPT code. 
 
The provider should have billed panel 81479 unlisted molecular pathology procedure. The medical records 
support 30 resulted. Instead, billed codes separately which are inclusive to the panel. Based on this information, 
we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided June 1, 2023.