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 and appliance provided 
on January 23, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not covered for use outside the home. 
 
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 and appliance provided on January 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by an out-of-
network provider from January 19, 2023, to January 26, 2023. 
 
You asked the Plan to pay for outpatient mental health services. You say that you prefer this doctor. The Plan 
denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that out-of-network 
outpatient mental health services require prior authorization.  
We looked at the file and Medicare rules. The services at issue were not authorized. Based on this information, 
we decided that Medicare rules for coverage of outpatient mental health services have not been met. Therefore, 
we decided that the Plan does not have to pay for outpatient mental health services provided by an out-of-
network provider from January 19, 2023, to January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99205) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis 
codes cannot be billed together. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes 1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes 1 note. An Excludes 1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, diagnosis code R73.9 has an Excludes1 note and cannot 
be billed with diagnosis code E11.40. As such, the claim is not payable as billed. 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 the services provided on December 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 30, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87798, 
87640, 87653, and 87651 for January 23, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with codes 87481, 87798, 87640, 87653, and 87651 for January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device (33289, C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 8, 2022, to 
August 15, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as Sepsis, 
unspecified organism, and secondary diagnosis code R65.20, described as Severe sepsis without septic shock. 
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 documentation does not support the billed code. Our physician 
reviewer found that the enrollee is a 93-year-old female with dementia who was treated in the hospital. The 
provided documentation described the enrollee as presenting with cough, shortness of breath following recent 
COVID-19 infection. She was awake and alert, had normal respiratory effort, chest X-ray was consistent with 
pneumonia. She had leukocytosis, normal platelets, Creatinine 1.16, troponin 71. She was treated with low dose 
oxygen, antibiotics, and fluids. Bilirubin was not provided. She did have hypotension. However, no other 
SOFA score contributed to supporting a sepsis diagnosis. There was insufficient evidence to show a life-
threatening dysregulated response to infection led to organ failure. Sepsis 3 criteria was not met. Therefore, the 
codes, A41.9 (sepsis) or R65.20 (severe sepsis) are 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 August 8, 2022, to August 15, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 24, 
2022, to November 25, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the criteria for acute inpatient level of care has not 
been met. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee is a 70-year-old male with Chronic obstructive pulmonary disease 
who presented with shortness of breath and hypoxia requiring oxygen support, steroids, antibiotics, 
bronchodilators, and fluids on transport and in the Emergency department. He was diagnosed with influenza 
and given Tamiflu. The enrollee was stable on low dose oxygen support (2L/m) and had no acute respiratory 
distress or accessory muscle use following initial treatments. He was admitted then discharged home on oxygen 
the next day. Based on the enrollee's stability and low severity, it was expected that he would not require 
hospital care that would likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided November 24, 2022, to November 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical supplies provided by an out-of-network 
provider on January 19, 2023. 
 
You asked the Plan to pre-approve medical supplies. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorize. 
 The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that durable medical 
equipment requires prior authorization. 
 
We looked at the file and Medicare rules. The supplies at issue were not authorized. Based on this information, 
we decided that Medicare rules for coverage of medical supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve medical supplies provided by an out-of-network provider on January 19, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device billed with code E0675 
for dates of service August 29, 2022, to September 19, 2022. 
 
You asked the Plan to pay for code E0675. You say that this item was medically necessary for the patient. 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 pneumatic compression devices coded with 
E0675 are not covered. You have billed the device in question with code E0675, so no coverage is available for 
this device. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0675 have not been met. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device billed with code E0675 for dates of service August 29, 2022, to September 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing billed with code G0482 on 
October 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says only one code per date of service is allowed. 
 
The Plan must follow Medicare rules. The rules say that only one definitive drug testing code may be reported 
per date of service. 
 
We looked at the file and Medicare rules. The file shows that code G0482 was billed for the same date of 
service G0480, which was approved by the Plan. Code G0482 cannot be approved for the same date of service. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the definitive drug testing billed with code G0482 
on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee has a qualifying condition for a Group 3 power wheelchair. You say that the enrollee has a history of 
pressure ulcers. You say that the enrollee requires assistance for transfers. You also say that the enrollee 
requires assistance for all mobility related activities of daily living (MRADLs). The Plan denied your request. 
The Plan says the record does not show that the enrollee needs both power tilt and power recline. The Plan says 
the the upgraded electronics are not medically necessary. The Plan also says that the elevating leg rests are not 
medically needed.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 power wheelchair with 
multiple power options. Our reviewer says that a Group 3 power wheelchair with multiple power options is not 
medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder or have spasticity that 
would necessitate power tilt or recline. The reviewer found that while the enrollees condition may meet 
criteria for a PWC, the criteria for the specifically requested PWC with multiple power options including power 
tilt and recline are not met. Therefore, the reviewer found that a Group 3 power wheelchair with multiple 
power options is not medically reasonable or 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with 
multiple power options and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. 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 lab services provided on October 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 29, 2022, to 
November 15, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you are an in-network 
provider and this claim should be reprocessed. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 29, 2022. The NOA was not received by the Plan until 
November 3, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided from October 29, 2022, to November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the micro foraminotomy to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the micro foraminotomy to be provided by an out-of-network (OON) 
provider. . You say that the service should be covered. The Plan denied your request. The Plan says the enrollee 
can continue to utilize the out-of-network provider but at the 
non-preferred benefit level 
 
Medicare rules say that plans the Plan must arrange for and cover any medically necessary covered benefit of 
the plan provider network, but at in-network cost sharing, when an in-network provider or benefit is 
unavailable or inadequate to meet a member's medical needs. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services with an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the micro foraminotomy to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service July 29, 
2022.  
 
You asked the Plan to pay for procedure code 99358. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says payment for code 99358 is bundled into payment for 
code 99310. 
 
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 99358 is a column II code to column I code 99310 with a modifier indicator of 0. The column II 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 99358 billed for date of service July 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel IRF services would be more suitable to 
regain maximum strength. The Plan denied your request. The Plan says you do not meet Medicare guidelines 
for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 an IRF admission and services.