Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on September 
06, 2023. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you want to appeal the amount 
being charged. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the telehealth visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 telehealth visit provided on September 06, 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 needs rehab to help them regain their 
strength as they need close supervision and assistance to move around. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on February 26, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high 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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the documented history and examination were appropriate; However, the documentation does not sufficiently 
support medical decision-making of high complexity as the enrollee was stable.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on February 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the CT scan of the abdomen and pelvis and the CT scan 
of the chest. 
 
You asked the Plan to pre-approve the CT scans. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested imaging does not meet coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scans. Our reviewer says that 
the requested imaging is not medically necessary. Our physician reviewer found the enrollee has not had an 
equivocal ultrasound or x-ray finding requiring further detailed imaging. Also, the enrollee's generalized edema 
is likely due to his known cardiac issues. Therefore, based on the provided documentation, the CT scan of the 
chest and the CT scan of the abdomen/pelvis will be considered not medically necessary 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 CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve  computed tomography (CT) of the abdomen and pelvis and a CT scan of the chest.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 14, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on September 14, 2023, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Multaq. 
 
You asked the Plan to pre-approve the medication. You say that you would like reconsideration based on the 
records submitted. 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 Multaq.  
 
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 pre-approve a Group 3 power wheelchair with a single power option 
(tilt, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with a single power option. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the records do not show a 
medical need for the requested power tilt. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with a single power 
option may be covered when certain 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 a Group 3 power wheelchair with a 
single power option. Our reviewer says that the requested Group 3 power wheelchair with a single power 
option is not medically necessary. Our physician reviewer found the provided records indicate that the enrollee 
does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with a single power option is not medically reasonable or 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 a Group 3 power wheelchair with a single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single 
power option (tilt, legrests) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says there is not a medical need 
for multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided records indicate that the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with multiple power options is not medically reasonable or 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone 
replacement graft (D7953) for tooth #15 provided on September 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied services. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the guided tissue 
regeneration and the bone replacement graft are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266) and the bone replacement graft (D7953) for tooth #15 provided on 
September 5, 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 meets the full medical and functional 
criteria for an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. Medically necessary 
services can be provided in 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: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99233 billed for date of service November 26, 2022. 
We decided that the Plan does not have to pay for procedure codes 99233 and 99239 billed for dates of service 
November 27, 2022, to December 1, 2022.  
 
You asked the Plan to pay for hospital care provided from November 26, 2022, to December 1, 2022. You say 
that these services were medically necessary and are supported as billed. The Plan says that the payment for 
code 99233 is included in the payment for code 99239 due to an NCCI edit, and there are insufficient records to 
support any date of service after November 26, 2022. 
 
We decided that the Plan has to pay for procedure code 99233 billed for date of service November 26, 
2022.  
 
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. We find that medical records were provided for the date in question, and only 
procedure code 99233 was billed for November 26, 2022. The NCCI edit cited by the Plan as a denial reason 
would only apply if the two codes at issue were performed and billed for the same date of service. The Plan has 
not provided a valid reason for denial of services provided on November 26, 2022. Therefore, we decided that 
the Plan has to pay for procedure code 99233 billed for date of service November 26, 2022.  
 
We also decided that the Plan does not have to pay for procedure codes 99233 and 99239 billed for dates 
of service November 27, 2022, to December 1, 2022. 
 
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 services provided from November 27, 
2022, to December 1, 2022, have been met. Specifically, there are no medical records for any date other than 
November 26, 2022. Without medical records which are clearly for the other dates at issue, we cannot verify 
any other services provided on this claim. Therefore, we decided that the Plan does not have to pay for 
procedure codes 99233 and 99239 billed for dates of service November 27, 2022, to December 1, 2022. 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that the patient was not on hospice on the date of 
service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 7, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for lab services provided on 
May 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external mobile cardiovascular telemetry (93229) provided 
on March 21, 2023.  
 
You asked the Plan to pay for external mobile cardiovascular telemetry. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the provider's signature is missing for the service in 
dispute. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic tests must be ordered by the 
physician who is treating the beneficiary. Medicare rules also say that services provided must be authenticated 
by the persons responsible for the care. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
The case file did not include any documentation to show that the services in dispute were ordered by a 
physician who is treating the beneficiary or that the services provided were authenticated by the person 
responsible for the enrollees care. Based on this information, we decided that the Medicare rules for coverage 
of mobile cardiovascular telemetry services have not been met. Therefore, we decided that the Plan does not 
have to pay for external mobile cardiovascular telemetry (93229) provided on March 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied home health physical therapy services and that the services requested are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation shows that the enrollee is able to ambulate a household distance and appropriate home health 
physical therapy goals have been met thus the records do not show that home health physical therapy services 
are required to effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 15, 2023, billed 
with procedure code P9603. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical records submitted does 
not include sufficient documentation to validate that the visiting technician collected the specimen on August 
15, 2023, therefore this service cannot be validated.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 15, 2023, billed with procedure code 
P9603.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine transportation trip totaling 86 miles. 
 
You asked the Plan to pre-approve routine transportation. You say that you need more mileage pre-approved 
for transportation to a facility for a computed tomography (CT) scan. The Plan denied your request. The Plan 
says that your transportation benefit must not exceed 75 miles of driving. 
 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 trips that do not exceed 75 miles of driving distance. 
  
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.  Therefore, we decided that the 
Plan does not have to pre-approve a routine transportation trip totaling 86 miles.