Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance services provided on July 14, 
2023. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that the services were medically 
necessary due to the enrollee's condition at the time of transport. The Plan denied your request. The Plan says 
the services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 
 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 non-emergent ambulance services. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found the record 
indicates that the enrollee was transported from an acute care facility to an assisted living facility. The record 
indicates that the enrollee was transported via stretcher. The record does not indicate that the enrollee's clinical 
condition is such that other methods of transport, such as stretcher van, are contraindicated or that the expertise 
services, lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide was 
required. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules. The elements of the coverage criteria are not satisfied. 
 
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 non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent ambulance services provided on July 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 29, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider was in-
network. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist office visit provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physical performance testing described by 6 units of code 97750 
performed on August 1, 2023. 
 
You asked the Plan to pay for 6 units of 97750. You say that 6 units of 97750 should be paid as billed because 
they are supported in the documentation. The Plan denied your request. The Plan says that 6 units of 97750 are 
denied because the medical record does not include documentation of a physician signature or attestation. 
 
The Plan must follow Medicare rules. Medicare rules say that when reviewing medical records, if it is 
determined that a valid signature is missing, the reviewer shall contact the person or organization that billed the 
claim and ask if the billing entity would like to submit an attestation statement or signature log within 20 
calendar days. 
 
We looked at the file and Medicare rules. The Plans denial rationale in this case was simply that the records 
were not signed and that the records provided for the appeal were duplicates of those previously received.  
However, the records submitted with the appeal did include an electronic signature. Though the signature was 
completed two months after the date of service, the rules do not indicate that a late signature would be grounds 
for denial. In fact, the verbiage of the rules suggests that a lack of signature could be remedied by a signature 
attestation in which the provider attests to the authenticity of the records and signs the attestation after the fact 
that it was determined that a signature was missing. There is no evidence in the case file that a signature 
attestation was requested by the Plan. As such, we find that the signature on the records is considered valid and 
that the Plans denial rationale is not substantiated. Based on this information, we decided that Medicare rules 
for coverage of 97750 have been met. Therefore, we decided that the Plan has to pay for the physical 
performance testing described by 6 units of code 97750 performed on August 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the fungal infection panel provided on April 19, 2023. 
 
You asked the Plan to pay for  the fungal infection. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not medically necessary. 
 
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 fungal infection. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found the treating physician's documentation did not explain why standard testing 
methods (microscopic examination, KOH prep, culture, staining) were not appropriate for this patient. PCR 
testing is excessive in this clinical scenario and is not yet supported by high quality evidence to lead to 
improved outcomes or be superior to standard testing methods. 
 
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 fungal infection have not been met. Therefore, we decided that the Plan 
does not have to pay for  the fungal infection panel provided on April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 25, 2022, 
to December 30, 2022, 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 the 
diagnosis code A41.9 (Sepsis, unspecified organism) is clinically validated by the medical records The Plan 
denied your request. The Plan says the billed principal diagnosis of A41.9 (Sepsis, unspecified organism) is not 
supported by the medical record. The correct primary diagnosis is J18.9 (pneumonia, unspecified organism). 
As a result, a lower DRG was paid. 
 
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 a principal diagnosis of A41.9 (Sepsis, unspecified 
organism). 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 reviewer says that the billed principal diagnosis of A41.9 (Sepsis, unspecified 
organism) is not supported by the medical record. Our physician reviewer found the enrollee is a 69-year-old 
male who was treated in the hospital with acute mental status changes following initiation of new oxycodone 
prescription for chronic pain with concern for possible overdose and was found to have pneumonia and 
rhabdomyolysis which were treated with antibiotics and fluids initially. Upon follow-up evaluation throughout 
the hospital stay, the enrollee was noted as alert and oriented without distress, no hypotension, normal platelets, 
normal bilirubin, normal platelet count, and creatinine which gradually trended down to 1.1 with fluids, 
however, an initial larger fluid bolus was not documented. The enrollee was noted to have hypoxia, however, 
this appeared to be expected due to the enrollee's pneumonia. The Sepsis-3 criteria is not met as there was not a 
Sequential Organ Failure Assessment (SOFA) of 2+ or sufficient evidence of organ failure directly related to a 
dysregulated response to infection as required. Therefore, the code, A41.9 (sepsis) is not supported for this 
admission.   
 
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 December 25, 2022, to December 30, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73590 and 96368 provided on June 3, 2023. 
 
You asked the Plan to pay for procedure codes 73590 and 96368. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules state that codes with a status indicator of Q1 are not 
separately payable. Medicare rules also say that providers must report services correctly. Providers must report 
services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the service in dispute was billed along with code 99284. 
Code 99284 has a status indicator of V. Billed code 73590 has a status indicator of Q1. This means that this 
code is not separately payable. Additionally, Medicare says that unconditionally packaged services are 
identified in the OPPS Addendum B with status indicator of N and these services are not paid separately since 
payment is included in the APC. Code 96368 is identified with a status indicator of N. Therefore, we decided 
that the Plan does not have to pay for procedure codes 73590 and 96368 provided on June 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the enrollee is improving with current treatment and should only require short-term additional acute care 
services that can safely be provided at the current facility until transfer to a lower level of care is appropriate. 
Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not already available and covered at the current 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting long term acute care 
hospital admission. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are improving with current treatment and should only require short-term 
additional acute care services that can safely be provided at the current facility until transfer to a lower level of care is appropriate. You do not require services at the LTACH that are not already available and covered at the 
current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81518 billed for date of service April 11, 
2023. You asked the Plan to pay for the billed service. You say that this is a covered diagnosis. The Plan denied your 
request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that certain codes are manifestation codes, denoted with a 
code first note, or in diseases classified elsewhere in the code definition. Another diagnosis code should be 
sequenced before a manifestation code if applicable.  
 
We looked at the file and Medicare rules. The claim was billed with primary diagnosis code Z17.0, defined as 
estrogen receptor positive status. This is not an appropriate primary diagnosis as it has a Code first note 
indicating to code the underlying condition first. 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 
81518 billed for date of service April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for eye examination and photos of the back of the eye provided on June 13, 
2023. 
 
You asked the Plan to pay for eye examination and photos of the back of the eye. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says that this service was not 
authorized. The Plan also says they require that an authorization must be obtained by you or the provider before 
the services are received. 
 
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 failed to submit the 2023 Evidence of Coverage (EOC). 
Without the EOC, we are unable to determine if you were denied coverage correctly. Therefore, we decided 
that the Plan has to pay for eye examination and photos of the back of the eye provided on June 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22513 provided on June 21, 2023. 
 
You asked the Plan to pay for procedure code 22513. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. 
 
In this case, procedure code 22513 was billed with diagnosis code M80.88XS for Other osteoporosis with 
current pathological fracture, vertebra(e), sequela. The diagnosis billed is inappropriate for the service. A 
sequela (7th character "S") code cannot be reported as the first listed/primary diagnosis on a claim because 
coding a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the 
sequela (7th character "S") code. Therefore, we decided that the Plan does not have to pay for procedure code 
22513 provided on June 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied home health services and that the services requested are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the member requires additional skilled rehab services to provide treatment 
that is 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kapspargo Sprinkle. 
 
You asked the Plan to pre-approve the medication. You say that the medication is essential to treat 
hypertension. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kapspargo Sprinkle.  
 
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25600 rendered on November 23, 2022. 
 
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 25600 54 RT (1 Unit) 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 25600 is "Closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed; without manipulation." 
 
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 being treated for 
fracture of the lower end of the right radius, closed fracture. She presented with pain to the right wrist. There is 
an obvious deformity of the right wrist. X-rays are consistent with a distal radial fracture with some mild 
angulation. She was placed in a volar splint and given a sling. There is no documentation of any unlar styloid 
involvement with the noted distal radial fracture. Therefore, the documentation does not support CPT 25600: 
closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed 
treatment of fracture of ulnar styloid, when performed; without manipulation 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 code 25600 rendered on November 23, 2022.