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

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you had a hip replacement, and you need a 
raised toilet for safety. The Plan denied your request. The Plan says the Plan and Medicare do not cover raised 
toilet seats because they are hygiene equipment, not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652). 
 
You asked the Plan to pre-approve the PCD. The Plan denied your request. The Plan says this item is not 
covered for lymphedema of the extremities. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0652 is not covered for the 
treatment of lymphedema of the extremities alone. 
 
We looked at the file and Medicare rules. The PCD in this case is being requested for lymphedema of the lower 
extremities. A PCD is not covered for this indication. Based on this information, we decided that Medicare 
rules for coverage of the PCD have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compression device (PCD) (E0652).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87507 billed for March 1, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 29, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 87507 billed for March 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 19, 2022, to June 
17, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary, 
so this claim should be paid. 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 May 19, 2022. The NOA was not received by the Plan until June 21, 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 
May 19, 2022, to June 17, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological testing evaluation. 
 
You asked the Plan to pre-approve psychological evaluation. You say that this testing is needed to determine 
the stability of the enrollee in hopes of being able to safely treat with a spinal cord stimulator. The Plan denied 
your request. The Plan says this 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 psychological evaluation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is diagnosed with chronic pain and is not showing any mental health 
issues. It is unclear how the testing would be used to benefit the enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological evaluation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve psychological testing evaluation.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines due to currently 
receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 You asked the Plan to pre-approve the therapy services. You say that you were injured and lost all progress 
from previous therapy. The Plan denied your request. The Plan says the requested services are not medically 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are not medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99213 billed for date of service April 7, 2023. 
 
You asked the Plan to pay for procedure code 99213. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
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. 
 
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's denial indicates that the services described by procedure 
code 99213 were provided on the same date of service as procedure code 20610 and that payment for 99213 is 
included in payment for 20610. Code 99213 was billed with modifier 24 to indicate an unrelated evaluation and 
management service by the same physician or other qualified health care professional. The Plan indicates that 
the provided records do not support the use of modifier 24. 
 
However, the Plan has not forwarded the provided records to us for independent review. It is the Plan's 
responsibility to support its denial with evidence. In this case, the Plan has not supported its denial, so we must 
find in your favor. Therefore, we decided that the Plan has to pay for procedure code 99213 billed for date of 
service April 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88173 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for the billed services. You say that the diagnosis codes represent what was 
performed. The Plan denied your request. The Plan says the diagnosis codes are mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 88173 is cytopathology, evaluation of fine needle 
aspirate; interpretation and report. 
 
The file shows that CPT code 88173 was billed with diagnosis codes H91.20, defined as sudden idiopathic 
hearing loss, unspecified ear; and H91.22, defined as sudden idiopathic hearing loss, left ear. We find that it is 
not accurate to bill a diagnosis code for the left side and a diagnosis code for an unspecified ear. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 88173 billed for date of service November 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve caudal epidural steroid injection. 
 
You asked the Plan to pre-approve caudal epidural steroid injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
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 caudal epidural steroid injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee did not 
achieve 50% pain relief for 3 months as specified in the LCD criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of caudal epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve caudal epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service May 1, 2023. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99213 is bundled into payment for code 36482.  
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 36482. 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 99213 billed for date of service May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 22, 2022, billed 
with evaluation and management (EM) code 99223-AI. 
 
You asked the Plan to pay for the practitioner services provided. You say that that there was no documentation 
of a comprehensive history or medical decision making of high complexity on the day of service in question. 
The Plan denied your request. The Plan says that the level of care 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 
that the level of care is not supported.  Our reviewer found that there was no documentation of a 
comprehensive history or medical decision making of high complexity on the day of service in question. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 22, 2022, billed with evaluation 
and management (EM) code 99223-AI.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on May 13, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that due to the enrollee's 
condition at the time of transport, any other means of transport would be unsafe. The Plan denied your request. 
The Plan says the enrollee did not require the expertise of trained personnel or the equipment available only in 
an ambulance in order to effectuate a safe transport.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
enrollee was transported from an acute care facility to an assisted living facility via stretcher.  The record does not indicate that the enrollee's condition was such that other methods of transport, such as 
stretcher, are contraindicated or that the expertise, services and lifesaving equipment that only a fully equipped 
ambulance can provide was required. The elements of coverage criteria 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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on May 13, 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 enrollee continues to need supervision from a 
physician, aggressive physical and occupational therapy to return to their previous level of function. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve azathioprine. 
 
You asked the Plan to pre-approve the medication. You say that the request for azathioprine is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve azathioprine. 
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the power wheelchair (E1399) purchased on April 
10, 2023. 
 
You asked the Plan to reimburse you for the power wheelchair. You say that the wheelchair that the enrollee 
received initially did not fit through doorways. You say that this wheelchair is narrower. You also say that you 
would rather backdate payment for the chair the enrollee already has rather than getting a new chair. The Plan 
denied your request. The Plan says the wheelchair was purchased prior to a physician order and therefore is not 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that if the supplier does not receive the 
order/prescription for the base item prior to delivery, the claim will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power wheelchair have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the power wheelchair (E1399) purchased on April 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99306) from an out-of-network (OON) 
provider on May 16, 2023. 
 
You asked the Plan to pay for OON nursing facility care. You say that these services were medically necessary. 
The Plan denied your request. The Plan says there is no authorization on file for the services provided. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that plans may offer a Point of Service (POS) option 
and may either require or waive prior authorization rules for obtaining POS services. The Plan contract states 
that prior authorization may be required for out-of-network physician/practitioner services other than primary 
care visits.  
 
We looked at the file and Medicare rules. The practitioner service at issue was not authorized. Based on this 
information, we decided that Medicare rules for coverage of OON nursing facility care have not been met. 
Therefore, we decided that the Plan does not have to pay for nursing facility care (99306) from an out-of-
network (OON) provider on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 17, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 17, 2023.