Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 11, 2022, to 
February 2, 2022. 
 You asked the Plan to pay for the home health services. You say that no definitive reason for denial was 
provided by the Plan. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied.  The Plan says that you filed invalid NOA claims on February 14, 2022, 
and March 14, 2022, but those were also not timely. 
 
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 January 11, 2022. The NOA was not received by the Plan until April 11, 
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 January 11, 2022, to February 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 23, 2022, 
to October 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you believe the admission date is 
correct. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 23, 2022, to 
October 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical services 
provided on December 16, 2022. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation with medical services. 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 psychiatric diagnostic 
evaluation with medical services provided on December 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 for date of service March 22, 2023. 
 
You asked the Plan to pay for procedure code 97110. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Review of the file shows that code 97110 was billed with diagnosis 
codes R26.9 (Unspecified abnormalities of gait and mobility) and R27.0 (Ataxia, unspecified). Due to an 
Excludes1 Note, these two diagnosis codes should not be billed together. Based on this information, we 
decided that Medicare rules for coverage of procedure code 97110 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 97110 for date of service March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection  
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says  a sacroiliac joint 
injection is 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 pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found the LCD coverage criteria requires 
50% pain relief for 3 months. However, there is no documentation showing the degree and duration of the pain 
relief that was achieved. Therefore, the request is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 28, 2022, to 
January 26, 2023. 
 You asked the Plan to pay for the home health services. You say that authorization is not required for these 
services. 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 December 28, 2022. The NOA was not received by the Plan until March 7, 
2023. 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 December 28, 2022, to January 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 13, 2022, to 
October 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA. 
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 July 15, 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 September 13, 2022, to October 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90715, 90471, and 70486 for date of service 
February 28, 2023. 
 
You asked the Plan to pay for procedure codes 90715, 90471, and 70486. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed.  
The Plan must follow Medicare rules. Medicare rules say that services must be billed correctly. 
 
We looked at the file and Medicare rules. Review of the file shows that procedure code 90471 has a status 
indicator of Q1. Procedure code 99284 was billed on the same claim, with the same date of service, with a 
revenue code of 450. This gives code 99284 a status indicator of V. Therefore, procedure code 90471, which 
has a status indicator of Q1 is not separately payable. Code 70486 has a status indicator of Q3. This is 
considered a "Single Major File" and is not separately payable as billed. Code 90715 has a status indicator of 
N. Codes with a status indicator of N are never separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 90715, 90471, and 
70486 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 90715, 
90471, and 70486 for date of service February 28, 2023.
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 services are medically necessary due to the 
enrollee's frequent falls. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Broda tilt wheelchair (E1399). 
 
You asked the Plan to pre-approve a Broda tilt wheelchair. You say that the enrollee is currently using this 
chair for trunk instability. The enrollee is currently borrowing the chair from another resident at the nursing 
facility she resides in. The Plan denied your request. The Plan says the enrollee is residing in a nursing facility, 
as such a standard wheelchair or a semi-reclining wheelchair are not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a Broda tilt wheelchair is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a Broda tilt wheelchair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on July 5, 2022, billed with 
Evaluation and Management (EM) code 99213-25. 
 You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is included in the global 
fee. 
 
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 99213 is a column II code to column I code 29405; however, 99213 
was billed with a modifier.  
 
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 Practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the report does not include 
documentation to support the modifier billed, as documentation describes the care of fracture. Therefore, this 
procedure cannot be verified as a separate identifiable service.  
 
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 Practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Practitioner services provided on July 5, 2022, billed with Evaluation and 
Management (EM) code 99213-25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames (V2020), spherocylinder, single vision 
(V2103), and anti-reflective coating (V2750) provided on March 22, 2023.  
You asked the Plan to reimburse for frames (V2020), spherocylinder, single vision (V2103), and anti-reflective 
coating (V2750). You say that you were advised to submit the claim directly to the Plan for reimbursement. 
The Plan denied your request. The Plan says services rendered by an out-of-network provider are not covered 
by the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are received in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say that you are responsible for all eyewear costs from 
providers outside of the Plan vision network. The record shows your services were received out-of-network. 
Based on this information, we decided that the Plan's rules for coverage of frames (V2020), spherocylinder, 
single vision (V2103), and anti-reflective coating (V2750) have not been met. Therefore, we decided that the 
Plan does not have to reimburse for frames (V2020), spherocylinder, single vision (V2103), and anti-reflective 
coating (V2750) provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3020).  
 
You asked the Plan to pre-approve foot orthotics. You say that you have severe pain in your foot, and you need 
the inserts to help you walk better and not fall as often. You also say that the provider advised you would get 
better with special shoes and with the inserts. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3020).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 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 the enrollee was admitted to the hospital on July 21, 2023 with septic shock. On 
August 2, 2023 it was documented that she had lactic acidosis and a poor prognosis. The enrollee is receiving 
acute hospital care and acute care services have not been denied. The documentation does not support that the 
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, 
that are not available at the current health care setting being offered by the health plan. Consequently, the 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator (implantable neurostimulator). 
 
You asked the Plan to pre-approve an auricular stimulator. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service is not covered by Medicare or the health plan. 
 
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 an auricular stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence that an implantable auricular stimulator is medically 
reasonable and necessary and is likely to impact outcomes in this 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 an auricular stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an auricular stimulator (implantable neurostimulator).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on February 1, 2023. 
 
You asked the Plan to pay for home health care. You say that these services should be approved. The Plan 
denied your request. The Plan says this claim was submitted with an incorrect Type of Bill. 
 The Plan must follow Medicare rules. Medicare rules say that home health prospective payment system claims 
must be billed with Type of Bill code 0327, 0328, or 0329.  
 
We looked at the file and Medicare rules. This claim was billed with Type of Bill 0324 which is not 
appropriate. Based on this information, we decided that Medicare rules for coverage of home health care have 
not been met. Therefore, we decided that the Plan does not have to pay for home health care provided on 
February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on February 8, 2023, billed 
with procedure code 96413. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim is 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 services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
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 Practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found the substance administered was not 
chemotherapy. There is a more specific code to report. 
 
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 Practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Practitioner services provided on February 8, 2023, billed with procedure 
code 96413.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on October 04, 
2022. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you believe there is a 
misunderstanding with this 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 $250 
copayment for in-network outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $250 copayment for the arthrocentesis. This item/service falls within the in-network outpatient surgery provided at an outpatient hospital 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 arthrocentesis provided on October 04, 2022.