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

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2023, 
to July 14, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. 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 subsequent nursing 
facility care provided on June 15, 2023, to July 14, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy visit provided on 
February 01, 2023, to July 12, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy visit. You say that you are asking for a 
reconsideration of the denied claim. 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. This item/service falls within the 
outpatient rehabilitation 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. You have been asked to pay a $40 copayment for each Medicare-covered visit. 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy visit 
provided on February 01, 2023, to July 12, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on November 
03, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you are requesting the 
copayment to be $0 instead of the $20. 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 rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy. This item/service falls within the outpatient rehabilitation 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 physical 
therapy provided on November 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on January 1, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as your 
request for reimbursement was received untimely.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
 
The Plans rules for coverage of gym benefits have not been met because your request for reimbursement was 
received untimely. Specifically, the Plans contract states that requests for reimbursement of the wellness 
allowance benefit must be received by March 31
st
 of the following year. However, your request was not 
received by the Plan until May 31, 2023, which was untimely. Therefore, we decided that the Plan does not 
have to issue reimbursement for the health club membership (S9970) purchased on January 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on June 16, 
2023, to July 14, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were unaware the provider 
was out-of-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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for physical therapy. This item/service falls within the outpatient rehabilitation 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 physical 
therapy provided on June 16, 2023, to July 14, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 36556 provided on June 29, 2023. 
 
You asked the Plan to pay for procedure code 36556. You say that the medical records support the billing of 
code 36556. The Plan denied your request. The Plan says that the medical records do not support the billing of 
code 36556. 
 
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 36556 is Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older. 
 
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 procedure code 36556. Our reviewer says that the medical 
records support the billing of code 36556. Our reviewer found the documentation supports that the services in 
question were rendered and appropriately coded. There is satisfactory documentation that a central line was 
placed via the internal jugular vein. There is satisfactory documentation that the line was placed centrally. As 
most central lines placed in the Intensive Care Unit (ICU) are not placed under fluoroscopic guidance, the exact 
location of the tip cannot be documented, and it is not reasonable to require this information to justify billing. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 36556 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 36556 provided on June 29, 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: 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 continued therapy at the SNF is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage of SNF care have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is currently in an inpatient rehabilitation facility (IRF), received oral 
medications, had stable vital signs, and was treated for a urinary tract infection (UTI) with delirium. The 
enrollee received physical therapy, speech therapy, and occupational therapy. The enrollee was at a supervision 
to moderate assist level with functional mobility, including gait to 20 feet. The enrollee required varying assist 
with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. However, they are not required on a daily basis. The enrollee does not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 the enrollee needs this service to have a better 
quality of life and to get stronger. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the carpal tunnel surgery to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the surgery. You say that you would like to see this provider. The Plan 
denied your request. The Plan says you must get your care from network providers. 
 
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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
carpal tunnel surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical pump 
(E2402) and related supplies (A6550). 
 
You asked the Plan to pre-approve the negative pressure wound therapy electrical pump and related supplies. 
You say that the enrollee has a chronic wound pressure that is a stage 4. You say that nothing has changed with 
the enrollee's wound stage. The Plan denied your request. The Plan says the request is not medically necessary 
because your records show you have not had debridement of devitalized tissue prior to re-initiation of NPWT. 
 
The Plan follows Medicare rules. Medicare rules say that negative pressure wound therapy pumps and related 
supplies are covered when specific criteria for coverage have been 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 the negative pressure wound therapy 
electrical pump and related supplies. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has diabetes and a stage 4 pressure ulcer of the sacrum. It is reported that 
the enrollee has had debridement in the past and has used negative pressure wound therapy in the past, but that 
it was discontinued as there was lack of healing with its use. The wound VAC failed to improve the enrollee's 
wound, and recent notes do not describe a recent debridement as required to consider negative pressure 
treatment. The negative pressure wound therapy is not considered medically necessary at this time.  
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 negative pressure wound therapy electrical pump and related supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a negative pressure wound 
therapy electrical pump (E2402) and related supplies (A6550).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an OasisSpace walker. 
 
You asked the Plan to pre-approve an OasisSpace walker. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the Plan has made available to you a standard folding rolling walker with seat and brakes. 
This item serves the same purpose as an OasisSpace walker. Therefore, we decided that the Plan does not have 
to pre-approve an OasisSpace walker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care to return to prior level of 
independence. The Plan denied your request. The Plan says the medical records do not support the need for an 
IRF admission. The Plan says that the enrollee's needs can be 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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, there is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status. The enrollee can receive further services 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service June 12, 
2023. 
 You asked the Plan to pay for procedure code 72170. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 72170 is bundled into payment for code 73501. 
 
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 72170 
is a column II code to column I code 73501. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 72170 billed for date of service June 12, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Reblozyl. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found the requested use of Reblozyl is FDA 
approved for the enrollee's condition. The documentation supports that Reblozyl is safe and effective for the 
enrollee's condition. Therefore, the request for Reblozyl should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve 
Reblozyl.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport and ground mileage services provided 
on May 8, 2023. 
 
You asked the Plan to pay for the ambulance transport services. You say that this claim is for authorized 
covered services, which the office rendered in good faith pursuant to your authorization. The Plan denied your 
request. The Plan says a physicians office is not a covered destination for non-emergency situations. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance transport and ground mileage services 
provided on May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0480) provided 
December 2, 2023 
 
You asked the Plan to pay for the laboratory services . You say that you are requesting reconsideration for 
services advising the coding department has reviewed the services and determined that the claim is coded 
correctly. The Plan denied your request. The Plan says the diagnosis codes should not be reported together 
which is based on the Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and 
Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The diagnosis codes associated 
to Z79.891 and F1120, should not be reported together. The billed service has been denied because it was 
reported with one or more diagnosis code pairs that are subject to an Excludes1 note. 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 (80307 and G0480) 
provided December 2, 2023
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment (93702). 
 
You asked the Plan to pre-approve BIS. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has 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 BIS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this testing method is not currently supported by high quality evidence compared to other 
standard screening methods, has a high false-negative rate, and is not accepted as the standard of care at this 
time. Therefore, this request for BIS will be considered not medically necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BIS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment 
(93702).