Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power operated vehicle (scooter) (E1230) and special 
service, procedure, or report (99199) purchased on July 1, 2023, from a provider that is not Medicare-certified. 
 
You asked the Plan to pay for the scooter and special service, procedure, or report. You say that you cannot 
afford to pay for the scooter. You also say that the provider is a Medicare-accepted provider. The Plan denied 
your request. The Plan says the provider is not a Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the scooter and special service, procedure or report have not been met. This provider is not part of 
the Medicare program and is not payable. The records also show that it was confirmed that there were no calls 
made by the provider to the Plan prior to the purchase date of the scooter. Therefore, we decided that the Plan 
does not have to pay for the power operated vehicle (scooter) (E1230) and special service, procedure, or report 
(99199) purchased on July 1, 2023, from a provider that is not Medicare-certified.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 93010 provided on June 19, 
2023. 
 
You asked the Plan to pay for procedure codes 99291 and 93010. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers and suppliers that render services or 
items to a prisoner or patient that is in custody should indicate this fact with the use of modifier QJ for claims. 
 
We looked at the file and Medicare rules. Medicare rules say that providers and suppliers that render services 
or items to a prisoner or patient that is in custody should indicate this fact with the use of modifier QJ for 
claims. The Plan will accept a corrected claim for review. Therefore, we decided that the Plan does not have to 
pay for procedure codes 99291 and 93010 provided on June 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says this request will exceed the 
maximum number of transportation trips allowed per year. 
 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 a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this will exceed the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service May 9, 2023.   
You asked the Plan to pay for procedure code 88377. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 11 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service May 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialty care transport and ground mileage provided on 
April 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for specialty care transport and ground mileage. You say that the services were 
medically necessary. The Plan denied your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for specialty care transport and ground mileage 
provided on April 23, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH level of care is appropriate 
and the only option for a safe discharge for the enrollee due to the need for frequent nursing care, respiratory 
therapy care, daily physician management, telemetry, continuous pulse oximetry monitoring, intravenous 
medication, and physical, occupational, and speech therapy. The Plan denied your request. The Plan says the 
records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care 
hospital.  
 
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 that the record indicates the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 15, 2023. 
 
You asked the Plan to pay for molecular testing. You say that you provide testing at the request of the ordering 
physician. The Plan denied your request. The Plan says this claim did not include the required DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a molecular diagnostic test service, 
provider should submit the appropriate procedure code, 1 unit of service, and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. This claim does not include the appropriate DEX Z-Code as is 
required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
molecular testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 
testing provided on May 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care and inpatient care provided 
on July 4, 2023, to July 11, 2023. 
 
You asked the Plan to waive the copayment for emergency care and inpatient care. You say that you disagree 
with the copayment. 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 $110 
copayment for emergency care and a $350 copayment per day for days 1-5 for inpatient hospital care.  
 
 You have been asked to pay a $110 copayment for emergency care and a $350 copayment per day for days 1-5 
for inpatient care. The total amount you owe for inpatient care is $700 ($350 x 2 days = $700). The total 
amount you are being asked to pay is $810 ($700 + $110 = $810). This item/service falls within the emergency 
care and inpatient hospital care 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 
emergency care and inpatient care provided on July 4, 2023, to July 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L3 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific 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 L3 kyphoplasty. Our reviewer says that 
you do not meet criteria for coverage. Our physician reviewer found detailed documentation is not evident 
regarding imaging corroboration of an osteoporotic compression fracture at the L3 level. Additionally, there is 
no documentation of a progression of the body height loss, greater than 25% vertebral body height loss, or 
kyphotic deformity. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible 
causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3 kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests (85014 and 85018) provided on April 14, 2023. 
 
You asked the Plan to pay for 85014 and 85018. You say that you do not have access to physician notes or 
reports. The Plan denied your request. The Plan says the records include a different clinical laboratory 
improvement amendments (CLIA) identifier than the claim form, so the location where the testing was 
performed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85014 is blood count; hematocrit. The CPT Code Manual 
definition of code 85018 is blood count; hemoglobin. 
 
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 85014 and 85018. Our reviewer says that these codes do not meet criteria for payment. Our reviewer found although the record includes documentation to support these 
services, the record contains conflicting information regarding the clinical laboratory improvement 
amendments (CLIA) number. The billing documents include CLIA number 05D0580198, but the laboratory 
report documents CLIA number 18D1092600. Therefore, the services cannot be verified as they have been 
billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 85014 and 85018 have not been met. Therefore, we decided that the Plan does 
not have to pay for lab tests (85014 and 85018) provided on April 14, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 would benefit from this care. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the criteria for an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is in fact complex and fragile. There is every reason to expect that the enrollee 
will participate in and benefit from services including physical therapy, occupational therapy, respiratory 
therapy and speech language pathology. The services should include any additional services that might be 
needed to make their current home environment sustainable to avoid admissions to the hospital. Therefore, the 
requested inpatient rehabilitation facility admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 25, 2023, billed with 
procedure code 99223. 
 
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 the claim was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, there is no documentation provided to verify the place of service code that was actually 
billed for the service in question. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on April 25, 2023, billed with procedure code 99223.
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 you would like to request reconsideration of the 
denied skilled nursing facility (SNF) services and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the skilled nursing facility (SNF) services requested do not meet the 
requirements for approval. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service December 27, 
2022. 
 You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says there is insufficient documentation to support the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records from the treating 
provider that show the intent for the services to be performed or that the testing was ordered to treat a specific 
medical problem. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the panel testing billed for date of service 
December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a speech modulation system. 
 
You asked the Plan to pre-approve speech modulation system. You say that this is needed so the enrollee can 
communicate better. The Plan denied your request. The Plan says the enrollee has a current speech modulation 
system that is within its reasonable useful lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of speech modulation system have been met. It is unclear what date the enrollees current speech modulation system was issued. Without this 
information, we cannot determine whether the enrollees current speech modulation system remains within its 
reasonable useful lifetime. The Plan requested supporting medical records related to this, but none were 
submitted. Please submit supporting medical records showing the age and condition of the enrollees current 
speech modulation system for consideration of replacement. Therefore, we decided that the Plan does not have 
to pre-approve a speech modulation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy administration services (96413 and 
96417) provided from March 30, 2023, to May 11, 2023. 
 
You asked the Plan to pre-approve 96413 and 96417. You say that these are payable codes. The Plan denied 
your request. The Plan says the sequencing order of the diagnosis codes is not correct. 
 The Plan follows Medicare rules. Medicare rules state that providers must comply with the official ICD-10-CM 
coding guidelines. 
 
We asked our coding 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 96413 and 96417. Our reviewer says 
that these codes do not meet criteria for payment. Our reviewer found the diagnosis codes were not reported in 
accordance with ICD-10 guidelines. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 96413 and 96417 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve chemotherapy administration services (96413 and 96417) provided from March 30, 
2023, to May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
from March 18, 2023, to April 6, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump (E0218). You say that this item was 
medically necessary. The Plan denied your request. The Plan says this is not a covered item. The Plan must 
follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is not covered 
by Medicare. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad with 
pump (E0218) provided from March 18, 2023, to April 6, 2023.