Persius/hicric huggingface dataset:
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine. The notes do not show 
that the enrollee has complex care needs that require a coordinated team approach. The notes do not show that 
the enrollee mush have an intensive therapy program in order to improve self-care functioning.  
 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care and can be 
provided in a lower level of care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but the services required can be provided at a 
lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the genetic testing provided on May 31, 
2023. 
 
You asked the Plan to reduce the coinsurance for the genetic testing. You say that the claim should be 
reprocessed at the in-network benefit level. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the genetic testing. This item/service falls within the 
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. The total amount the enrollee owes is $583.92 
($2,919.60 allowed amount x 20% = $583.92). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for the genetic testing provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM will help you monitor how different food 
choices impact your glucose numbers.  The Plan denied your request. The Plan says the Medicare criteria was 
not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is not having low blood sugars that we are told of and is 
not taking insulin. Although a CGM might help the enrollee adjust diet and control their blood sugars, the 
coverage criteria are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 23, 
2023, to April 6, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services were necessary and should be paid.  The 
Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay out of network. 
 
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 pay for 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. The provided care, however, does not appear to have been emergent or urgent.  The care was ongoing 
care for a known wound and was foreseeable.  As such, the out of network care is not coverable, unless 
previously authorized. 
 
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 pay for skilled nursing facility (SNF) care provided from March 23, 2023, to April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services, and remote physiologic 
monitoring services provided on February 23, 2022, to July 31, 2022. 
 
You asked the Plan to pay for chronic care management services, and remote physiologic monitoring services. 
You say that these services were medically necessary. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chronic care 
management services, and remote physiologic monitoring services provided on February 23, 2022, to July 31, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) service 
provided on June 20, 2022, to December 12, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) service. You say that you met your 
maximum out-of-pocket in June 2022. 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 $30 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for each physical therapy (PT) service. This item/service falls 
within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. You have been asked to pay $385 for PT services. Your maximum out-of-
pocket of $7,550 was not met at the time the claims were processed. Therefore, we decided that the Plan does 
not have to waive the copayment for each physical therapy (PT) service provided on June 20, 2022, to 
December 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 8, 2023, to April 
6, 2023.  
 You asked the Plan to pay for the home health services. You say that this claim has not been paid, and home 
health services are a covered benefit. 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 8, 2023. The NOA was not received by the Plan until April 25, 
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 March 8, 2023, to April 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
April 25, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (83036 and 83719) provided on 
September 7, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for OON laboratory services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says out-of-network services are only 
covered in certain limited circumstances which have not been met in this case. Neither the rendering nor the 
referring providers in this case are in-network with the Plan. 
 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 laboratory services (83036 and 83719) provided 
on September 7, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test, 1-7 classes (G0480) and mass spectrometry and 
tandem mass spectrometry (83789) provided on June 30, 2023. 
 
You asked the Plan to pay for the drug test, 1-7 classes (G0480) and mass spectrometry and tandem mass 
spectrometry (83789). The Plan denied your request. The Plan says procedure code G0480 cannot be verified. 
The Plan also says procedure code 83789 is considered inclusive to procedure code G0480 and cannot be 
separately reimbursed. 
 
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 83789 is a column II code to column I code G0480; however, 83789 
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 drug test, 1-7 classes (G0480) and mass spectrometry and 
tandem mass spectrometry (83789). Our reviewer says that the documentation does not support procedure 
codes G0480 and 83789. Our reviewer found that the records do not include a physician order to support the 
service provided billed with code G0480, as well as physician intent. Therefore, this procedure code cannot be 
verified. In addition, the laboratory report describes urine drug testing with specimen validity. In this case, 
testing to confirm that a urine specimen is unadulterated is an internal control process that is not separately 
reportable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug test, 1-7 classes (G0480) and mass spectrometry and tandem mass 
spectrometry (83789) have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
test, 1-7 classes (G0480) and mass spectrometry and tandem mass spectrometry (83789) provided on June 30, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service March 24, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says no laboratory order for definitive/confirmative drug test(s), 22 or more drug classes 
was provided 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation included 
a physician's order; however, did not include a laboratory order for definitive/confirmative drug test(s), 22 or 
more drug classes. Therefore, the services billed cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the Plan does not 
have to pay for code G0483 for date of service March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee tolerated bilevel positive 
airway pressure (BIPAP) and had improvement of symptoms and titrated down to at night BIPAP with oxygen 
(O2) during the day. There was no documented failure of BIPAP, hence does not require home ventilator. The 
patient can sufficiently be treated with BIPAP once a day at bedtime (qhs). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary because based on the medical literature 
this procedure is considered experimental or investigational and has not been proven to be beneficial for the 
enrollee's condition. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental procedure. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization (36246, 36247).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and 
outpatient diagnostic tests provided on June 5, 2023, to June 19, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and outpatient diagnostic 
tests. You say that you disagree with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $275 copayment for outpatient diagnostic 
tests/outpatient hospital.  You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs and a $275 copayment 
for outpatient diagnostic tests. The total allowed amount for the prescription drugs is $5,943.50. You are being 
asked to pay $1,188.70 ($5,943.50 x 20% = $1,188.70). The total amount you are being asked to pay is 
$1,463.70 ($1,188.70 + $275 = $1,463.70). This item/service falls within the Medicare Part B prescription 
drugs and outpatient diagnostic tests/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 cost share for Medicare Part B prescription drugs and outpatient diagnostic tests provided on June 5, 2023, 
to June 19, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87624, 88175 and 88141 billed for date of service 
June 20, 2023.  
 
You asked the Plan to pay for procedure codes 87624, 88175 and 88141. You say that it was necessary for each 
of these tests to be performed twice, as the enrollee has two cervixes and therefore had two separate specimen 
sites. The Plan denied your request. The Plan says that the billed number of units are not supported by the 
records as both provided and medically necessary.  
 
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 codes 87624, 88175 and 88141 is 1 for each code. The MAI value for this code 
is 3. You billed 2 units of this code, exceeding the MUE.  
 
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 additional unit of codes 87624, 88175 
and 88141. Our reviewer says that the services at issue in this case are supported by the medical records. Our 
reviewer found the documentation does reflect that additional units were performed, and documents that the 
patient has 2 cervixes, so they are medically necessary. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87624, 88175 and 88141 have been met. Therefore, we decided that the Plan 
has to pay for procedure codes 87624, 88175 and 88141 billed for date of service June 20, 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.