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 the enrollee needs intense therapy from multiple 
disciplines to maximize functional independence with self-care, mobility, transfers, and to reduce caregiver 
assist, fostering a safe return home. The Plan denied your request. The Plan says the enrollee's records do not 
show a complex rehabilitation need that would necessitate evaluation by a rehabilitation doctor 3 times per 
week. 
 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on September 13, 2022, billed 
with code 71045-26-77. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. 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 October 24, 2022. 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 the imaging services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on September 13, 
2022, billed with code 71045-26-77.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on February 
27, 2023. 
 
You asked the Plan to pay for these services. You say that the provider is in-network and you do not understand 
why the claim was denied. The Plan denied your request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Licensed Professional Counselor (LPC) is not eligible 
to participate in Medicare.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered by a Licensed 
Professional Counselor. This provider type is not covered by Medicare. Therefore, we decided that the Plan 
does not have to pay for the outpatient mental health services rendered on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an electrocardiogram provided on October 
12, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit and an electrocardiogram. You say that this was 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 an office visit and an electrocardiogram provided 
on October 12, 2022, by an out-of-network (OON) provider.
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 need the intensive therapy services. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of medial malleolus fracture (27766) 
provided on January 19, 2023. 
 
You asked the Plan to pay for the open treatment of medial malleolus fracture (27766). You say that the 
attending surgery felt an assistant surgeon was necessary to properly and safely perform the surgery. You say 
that operative notes should be reviewed and the denial of procedure code 27766 reconsidered. The Plan denied 
your request. The Plan says this procedure does not allow for assistant surgeon payment. 
 The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27766. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
open treatment of medial malleolus fracture (27766) have not been met. Therefore, we decided that the Plan 
does not have to pay for the open treatment of medial malleolus fracture (27766) provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for a lightweight wheelchair purchased on 
February 19, 2023. 
 
You asked the Plan to provide reimbursement for a lightweight wheelchair. You say that a wheelchair is 
covered by your insurance. The Plan denied your request. The Plan says that the provider is not enrolled in the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for a lightweight 
wheelchair purchased on February 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on October 19, 2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the claim was file untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent hospital care was not filed until December 21, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided on  
October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies billed with codes A7030, A7035, A7031 for date of 
service December 28, 2021. 
 
You asked the Plan to pay for supplies billed with codes A7030, A7035, A7031. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or a proof of delivery. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
supplies billed with codes A7030, A7035, A7031 for date of service December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on February 22, 2023. 
 
You asked the Plan to pay for the home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. 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 the home visit 
evaluation provided on February 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
December 6, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until February 11, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated knee orthosis. 
 
You asked the Plan to pre-approve a custom fabricated knee orthosis. You say that the requested custom 
fabricated knee orthosis is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for a custom fabricated knee orthosis.  
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 a custom fabricated knee orthosis. Our 
reviewer says that the enrollee does not meet criteria for a custom fabricated knee orthosis. Our physician 
reviewer found the LCD L33318 is very specific in its documentary requirements for coverage of a custom 
fabricated knee orthosis  the key hurdle being that the medical record must explicitly include a discussion of 
why the enrollee cannot be treated with a prefabricated alternative. 
 
It is notable that the prescriber specifically ordered a custom fabricated brace, and the appellant is correct that 
the evidence suggests that off-loader braces are effective and well within the standard of care generally.  
However, the review of the enrollee's file finds no discussion whatsoever of why a prefabricated orthosis would 
not meet the enrollees needs. Therefore, at this time, and per the record presently available, the Plans denial 
of L1846 is upheld. 
 
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 custom fabricated knee orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a custom fabricated knee orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 30, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these items 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 the wound care supplies 
provided on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on December 
13, 2022. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy (81455) provided on December 13, 2022.
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 enrollee cannot control their glucose levels. 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 CGM coverage criteria requires 
insulin use or low blood sugars; this enrollee is not having low blood sugars nor are they on medications that 
would cause them as now they are only taking Metformin. Although, the CGM might help them monitor their 
blood sugar levels and adjust diet accordingly to blood glucose level, the criteria for coverage 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator array, 
peripheral nerve. 
 
You asked the Plan to pre-approve the services. You say that the services should be covered and are medically 
necessary. The Plan denied your request. The Plan says there has not been a formal psychological screening or 
nerve stimulator trial yet. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case do not document screening, evaluation, and diagnosis by a 
multidisciplinary team prior to implantation including a psychological, as well as physical evaluation.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of a neurostimulator array, peripheral nerve.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on January 12, 2016. 
 
You asked the Plan to pay for the laboratory services. You say that the member's physician sent the specimen 
to the lab for testing. The Plan denied your request. The Plan says that the services were sent too late for 
processing for payment. 
 
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 has not provided documentation to substantiate their 
denial. Therefore, we decided that the Plan has to pay for laboratory services provided on January 12, 2016.  
 
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 laboratory testing (81479) billed for date of service February 
5, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (81479) 
billed for date of service February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on March 25, 2022. 
 
  You asked the Plan to pay for initial hospital care (99222). You say that the corrected claim was submitted with 
only modifier 25, which allows this code to be processed separately from the angiography procedures 
performed on the same day of service. You say that claim should be reprocessed. The Plan denied your request. 
The Plan says the incorrect POS code was billed. 
 
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 99222 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 moderate 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 moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the enrollee was under 
outpatient observation on this date of service, but the inpatient POS code was billed. Based on this information, 
we decided that Medicare rules for coverage of initial hospital care (99222) have not been met. Therefore, we 
decided that the Plan does not have to pay for initial hospital care (99222) provided on March 25, 2022.