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

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 188.5 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
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 the services are medically necessary. The Plan 
denied your request. The Plan says the notes do not show that the enrollee needs daily therapy that can only be 
given at a skilled nursing level. 
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the reconsideration of the 
denial for the LTACH level of care admission to be reconsidered based on the information you have provided. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does 
not require a transfer 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 the patient is receiving appropriate care in current acute care setting as provided by 
Health Plan. Our reviewer also found that the documentation does not support that LTACH services are 
medically appropriate 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 15, 2022, to June 
13, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted 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 March 14, 2022. The NOA was not received by the Plan until June 8, 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 
April 15, 2022, to June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 2, 2022, to May 
6, 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 this 
claim was billed correctly and the DRG should not have been changed. The Plan denied your request. The Plan 
says the principal diagnosis of N17.9, Acute kidney failure, unspecified, is not supported by the medical record. 
The principal diagnosis should be E86.0- Dehydration. 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 N17.9, (Acute kidney 
failure, unspecified). 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 diagnosis of N17.9, Acute kidney 
failure, unspecified, is not supported by the medical record. Our physician reviewer found the enrollee is an 87-
year-old female who presented with generalized weakness, anorexia, nausea, vomiting, diarrhea, with recent 
management for dehydration, leukopenia related to stage IV lung cancer and associated radiation and 
chemotherapy. However, the principal diagnosis of N17.9, Acute kidney failure, unspecified, is not supported 
by the medical record.  Her baseline Cr was reported as 1.7 in 2020. Creatinine was 1.9 with BUN 79 
suggesting prerenal azotemia such as dehydration. She was treated with fluids, blood transfusion, and platelet 
transfusion. Repeat Cr was 1.6 and BUN 63.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 2, 2022, to May 6, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 19, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that the coding and diagnosis are approved by 
Medicare. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. The urinary tract infection panel was not billed with a single code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 19, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 96365-59, 96366-59, and 96521 billed for date of 
service May 30, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says that records were not received timely. 
 
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. 
 
We looked at the file and the rules. The Plans redetermination letter states that code 96365-59 was being 
processed as a reopen based on new evidence. The Plans letter also states that 1 unit of code 96365-59 was 
being upheld. The claim information shows that only 1 unit of code 96365-59 was billed. The Plan cannot send 
the code to reopen and uphold the code at the same time. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 96365-59, 96366-59, and 96521 billed for date of service 
May 30, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on March 8, 2023, billed with procedure 
codes B4199, B4224, and B4220. 
 
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 that documentation does not support the billed 
codes. 
 
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 B4199, B4224, and B4220 is parenteral nutrition solution; compounded amino acid and carbohydrates 
with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - 
premix, parenteral nutrition administration kit, per day, and parenteral nutrition supply kit; premix, per day. 
 
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 support the billed codes Our reviewer found that these codes are listed in the 
documentation. 
 
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 been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on March 8, 2023, billed with procedure codes B4199, 
B4224, and B4220.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prophylaxis - adult (D1110), and 
periodic oral evaluation - established patient (D0120) provided on May 15, 2023. 
 
You asked the Plan to waive the coinsurance for the prophylaxis - adult and periodic oral evaluation. You say 
that you paid the full $167.00 and was expecting this to be your reimbursement. 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% 
coinsurance for out-of-network non-Medicare covered preventive dental services.  
 
You have been asked to pay a 20% coinsurance for the prophylaxis - adult and periodic oral evaluation.  
 This service falls within the dental services (additional) 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 coinsurance for the prophylaxis - adult (D1110), and periodic oral evaluation - established patient (D0120) 
provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service May 19, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code 99284 is not substantiated by the clinical 
documentation. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
 
 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 99284. Our reviewer says that the code billed 
is not supported. Our reviewer found the enrollee presented to the Emergency Department on May 19, 2023, 
for staple removal from the scalp which he got placed on May 12, 2023, due to a fall and laceration. He denied 
any complaints and reported that the wound had healed well. Physical exam: staples in place at left parietal 
area, wound looks well healed. The enrollee was stable, with normal vital signs and normal lab work. There 
was no sign of multiple system dysfunction nor a need for specialty consultation. The presentation was not one 
of high severity requiring urgent evaluation and no acute situation of a complex nature to support the level of 
care billed. The review has determined that the documentation did support a medically appropriate history 
and/or examination but not a moderate level of medical decision making. 
 
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 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 for date of service May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external mobile cardiovascular telemetry (93229) provided 
on June 27, 2022. 
 
You asked the Plan to pay for 93229. You say that this testing was ordered by the referring physician. The Plan 
denied your request. The Plan says the records do not include a monitoring order with the name of the ordering 
physician to verify this 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 93229 is external mobile cardiovascular telemetry with 
electrocardiographic (ECG) recording, concurrent computerized real time data analysis and greater than 24 
hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days, review and interpretation with report by a physician or other qualified health care profession. Technical support for connection and patient instructions 
for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a 
physician or other qualified health care profession for reimbursement consideration. 
 
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 93229. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the medical record does not include a physician order for the service 
provided. Also, this procedure code represents the technical portion of testing. The record does not include 
documentation of connection and patient instruction for use and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 93229 have not been met. Therefore, we decided that the Plan does not have to 
pay for external mobile cardiovascular telemetry (93229) provided on June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy. 
 
You asked the Plan to pre-approve the drugs. You say that the enrollee has cancer and cannot wait for 30-day 
turnaround time to process the appeal. The Plan denied your request. The Plan says Opdivo and Yervoy are not 
medically necessary.  
 
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 the drugs. Our reviewer says that 
Opdivo and Yervoy are not medically necessary.  Our physician reviewer found that the requested use of 
Opdivo and Yervoy is not FDA-approved. Opdivo and Yervoy is also not supported by one of the major drug 
compendia or by clinical research. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo and Yervoy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on May 19, 2023. 
 
You asked the Plan to waive the copayment for an x-ray. You say that the x-ray should be included with your 
office visit. 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 $55 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $55 copayment for an x-ray. This item/service falls within the in-network 
outpatient diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is less than the 
standard copayment, you only owe $20. Therefore, we decided that the Plan does not have to waive the 
copayment for an x-ray provided on May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you have multiple 
sclerosis and do not have the strength to maneuver a manual wheelchair that you are being provided. The Plan 
denied your request. The Plan says the requested group 2 powered wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 2 standard power wheelchair. 
Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found you do not 
require a power wheelchair to perform MRADLs in the home. Our reviewer also found that you are a 
functional ambulator in your home. 
 
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 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).