Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening for depression and safety concerns screen provided 
provided on July 12, 2023. 
 
You asked the Plan to pay for screening for depression and safety concerns screen provided. You say that the 
services 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 screening for depression 
and safety concerns screen provided provided on July 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for LTACH services provided from April 1, 2022, to  
April 13, 2022.  
 
You asked the Plan to pay for the LTACH services. You say that the LTACH services were medically 
necessary. The Plan denied your request. The Plan says the LTACH services were not medically necessary. 
 
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 pay for 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 that the provided records do not explain what care services were provided in the LTACH that 
were not available at a lower level of care such as a skilled nursing facility (SNF) from April 1, 2022, through 
April 13, 2022. As of the dates in question, the enrollee was extubated, the tracheostomy had been discontinued 
and the site was healing. The enrollee was on an oral diet, seizure-free with improved mental status, medically 
stable and receiving physical and occupational therapy, all of which could have been provided in a SNF. The 
LTACH provided no services from April 1, 2022, through April 13, 2022 that could not have been provided in 
a SNF. 
 
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 pay for LTACH services provided from April 1, 2022, to April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus and diphtheria toxoids adsorbed (Td) (90714), 
and administration (90471) provided on July 24, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that your primary doctor recommended this 
vaccine. The Plan denied your request. The Plan says the services are not covered under the Medicare Part B 
benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus and diphtheria toxoids 
adsorbed (Td) (90714), and administration (90471) provided on July 24, 2023.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services 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 an office visit provided 
on June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 29, 2023. 
 
You asked the Plan to pay for the home visit. You say that you say that the provider is in-network. 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 home visit provided 
on June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 7, 2023, to May 
12, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis code, J96.01 (Acute Respiratory Failure with Hypoxia) was accurately assigned and 
reported with the appropriate billed DRG.  The Plan denied your request. The Plan says Even though J96.01 
Acute respiratory failure with hypoxia is documented in the progress notes and in response to a physician 
query, supporting medical record documentation was not found within the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, defined as acute 
respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply 
the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our physician reviewer found that there was no evidence of an 
arterial blood gas showing hypoxia or evidence of the patient requiring or being treated with high flow oxygen, 
BiPAP, or vent support as required. Also, there was no evidence of persistent respiratory distress as required to 
meet criteria for acute respiratory failure. Therefore, the secondary diagnosis code assignment of J96.01 Acute 
respiratory failure with hypoxia is not sufficiently supported in the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 7, 2023, to May 12, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 06, 
2023. 
 
You asked the Plan to waive the copayment for laboratory services. 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 tests/lab serices. 
 
You have been asked to pay a $10 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/lab serices 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 
laboratory services provided on July 06, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance supplies received on June 19, 2023, through 
June 27, 2023. 
 
You asked the Plan to pay for the ambulance supplies. The enrollee says that the services were medically 
necessary their bleeding. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the ambulance supplies received on June 19, 2023, through 
June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on June 20, 2023, and billed 
with codes 87481, 87798, 87640, 87653, 87556, 87651, and 87641. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the laboratory panel have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory panel provided on June 20, 2023, 
and billed with codes 87481, 87798, 87640, 87653, 87556, 87651, and 87641.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the attached 
medical record proves the enrollee meets medical necessity. The Plan denied your request. The Plan says the 
enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial 
of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance transportation services provided on September 14, 2022. 
 
You asked the Plan to pay for the air ambulance transportation services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that only local transportation by ambulance 
is covered. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were medically necessary. Our physician reviewer found the enrollee 
required transport for a higher level of care. Ground transport was not available at the time the services were 
rendered. The treating hospital did not have adequate resources. Therefore, the services do meet the 
requirements for approval. 
 
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 air ambulance services have been met. Therefore, we decided that the Plan 
has to pay for air ambulance transportation services provided on September 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on July 28, 2023. 
 
You asked the Plan to pay for wound care supplies. 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 wound care supplies 
provided on July 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 23, 2022. 
 You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on October 
23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial with supporting 
documentation. 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 laboratory service 
provided on June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 13, 
2023. 
 
You asked the Plan to waive the copayment for laboratory services. 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 $20 
copayment for outpatient diagnostic test/lab services. 
 
You have been asked to pay a $20 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic test/lab 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. Therefore, we decided that the Plan does not have to waive the copayment for 
laboratory services provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning including the explanation provided on 
June 21, 2023. 
 
You asked the Plan to pay for advance care planning including the explanation. 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 advance care planning 
including the explanation provided on June 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 25560 and 26600 rendered on May 29, 
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 the denied codes remain 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 the denied codes is: 
 
CPT 25560: 
 
Closed treatment of radial and ulnar shaft fractures; without manipulation  
CPT 26600: 
 
Closed treatment of metacarpal fracture, single; without manipulation, each bone 
 
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 enrollee was provided with 1 
dose of Rocephin 1-gram intravenous and had lab work as well as imaging studies. She was placed in a sugar-
tong splint on the right arm. However, this was for the treatment of a distal ulnar diaphyseal mildly displaced 
fracture and there is no mention of any radial shaft fractures or ulnar shaft fractures. Moreover, the splint that 
was placed was a sugar-tong splint which would typically not be utilized for treatment of a metacarpal fracture. 
The documentation does clearly document that the splint applied was including immobilization of the 5th 
metacarpal fracture. Therefore, the documentation does not support that CPT 25560: closed treatment of radial 
and ulnar shaft fractures without manipulation and CPT 26600: closed treatment of the metacarpal fracture, 
single; without manipulation, each bone was rendered in this case. 
 
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 codes 25560 and 26600 rendered on May 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual-wheelchair repair services. 
 
You asked the Plan to pre-approve wheelchair repairs. You say that the requested wheelchair repairs are a 
necessity for the enrollee's care. The Plan denied your request. The Plan says rules for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs to equipment which a beneficiary owns 
are covered when necessary to make the equipment serviceable. If the expense for repairs exceeds the 
estimated expense of purchasing or renting another item of equipment for the remaining period of medical 
need, no payment can be made for the amount of the excess. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wheelchair repairs have not been met. Specifically, the case record shows that the estimated cost of 
the requested repairs exceeds the estimated cost of replacing the item at issue. 
   Therefore, we decided that the Plan does not have to pre-approve manual-wheelchair repair services.  
 
Please note that if a replacement wheelchair is desired, requests for replacement should be directed to the Plan.