Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 25, 2023, to April 
28, 2023. 
 
You asked the Plan to pay for home health. You say that you are appealing with supporting records. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health services provided from April 25, 2023, to April 
28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from December 11, 
2022, to December 20, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
physician clearly documents that the symptoms and findings were due to sepsis. You say that sepsis meets the 
criteria for reporting and DRG 853 is the correct assignment. The Plan denied your request. The Plan says the 
records do not validate diagnosis code A41.9, which resulted in a DRG change. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code A41.9, defined as sepsis, unspecified 
organism. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the billing of A41.9 is not supported. Our physician reviewer 
found the enrollee presented with a labial wound, which was consistent with Fourniers gangrene. The enrollee 
underwent operative debridement and received antibiotics. The hospitalization was complicated by the 
formation of upper extremity deep vein thrombosis; however, there is no evidence that the enrollee has sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from December 11, 2022, to December 20, 2022, at the DRG originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis procedure provided on May 
25, 2023, to June 29, 2023. 
 
You asked the Plan to waive the coinsurance for each dialysis procedure. You say that you were told that this 
service would be fully covered. 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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for each dialysis procedure. This item/service falls within the 
services to treat kidney disease 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 amount you owe for each dialysis procedure is $58.48 ($292.38 allowed 
amount x 20% = $58.48). The total amount you owe is $877.20 ($58.48 coinsurance x15 visits = $877.20). 
Therefore, we decided that the Plan does not have to waive the coinsurance for each dialysis procedure 
provided on May 25, 2023, to June 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 26, 2021. 
 
You asked the Plan to pay for the abulance services. The Plan denied your request. The Plan says payment is 
included in the SNF payment. 
 
The Plan must follow Medicare rules. Medicare rules say that  ambulance services are separately reimbursable 
only under Part B. Once a beneficiary is admitted to a hospital, CAH, or SNF, it may be necessary to transport 
the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains 
inpatient status with the original provider. This movement of the patient is considered "patient transportation" 
and is covered as an inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a 
covered SNF service and payment is made under Part A for that service.  
We looked at the file and Medicare rules. Payment for the ambulance services in this case is included in the 
SNF rate. The ambulance services are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the abulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) (77523). 
 
You asked the Plan to pre-approve PBRT. You say that the services are medically necessary. The Plan denied 
your request. The Plan says a review of the literature indicates that PBRT is not the standard of care for 
prostate cancer. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible 
advantage of this expensive therapy. The bottom line is that proton therapy for prostate cancer is not experimental, and in fact is an accepted treatment approach. While the reviewer does not think that proton 
therapy is an experimental therapy, any potential benefit or detriment of proton therapy over standard intensity 
modulated radiation therapy (IMRT) is an investigational question (being pursued in randomized studies- i.e., 
for intermediate to low-risk prostate cancer). To date, there are no compelling data to suggest that proton 
therapy is superior to or more beneficial than IMRT/image guided radiation therapy (IGRT). The generally 
accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not 
routinely offer it to patients. While National Comprehensive Cancer Network (NCCN) guideline consider 
proton therapy a reasonable alternative they do not describe it as being necessary in lieu of non-proton-based 
treatment and are quite explicit in that there is no evidence of its superiority. The decision is unfavorable as the 
reviewer does not believe the LCD criteria are 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 PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT) (77523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 20, 2023, billed with 
procedure codes 74018 and 72170. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an unacceptable 
principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that there are selected codes that describe a 
circumstance which influences an individuals health status but not a current illness or injury, or codes that are 
not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as 
a principal diagnosis.   
 We looked at 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. We have confirmed that this claim was billed 
with an unacceptable principal diagnosis. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on April 20, 2023, billed with procedure codes 74018 and 72170.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on June 7, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 the office visit (99215) provided on June 7, 2023, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you need physical therapy out of network. 
The Plan denied your request. The Plan says the physical therapy can be provided in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service May 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test directly impacts clinical decision 
making. The Plan denied your request. The Plan says screening services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that the panel testing was ordered due to a family history of cancer. Medicare does not cover 
this test solely for screening purposes. The panel testing was not billed with a single code as required. Based on 
this information, we decided that the Medicare rules for payment have not been met. Therefore, we decided 
that the Plan does not have to pay for the panel testing billed for date of service May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator provided on March 9, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a portable oxygen concentrator. You say that the claim should be reprocessed. 
The Plan denied your request. The Plan says a portable oxygen concentrator is available in network. 
 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 a portable oxygen concentrator provided on March 
9, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64447) provided on May 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code was billed 
without an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 64447 is not supported in the medical record. Specifically, code 64447 was 
not billed with an appropriate anatomic modifier in this case. 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 pay for the services (64447) provided on May 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation codes A0425 and A0427 billed for 
date of service April 2, 2023. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that certain diagnosis codes have an Excludes1 note which lists 
other diagnosis codes with which they cannot be reported.  In this case, we have confirmed that R52 has an Excludes1 note in relation to R10.-. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance transportation codes A0425 and A0427 billed for date of service April 2, 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 items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they do not meet the clinical 
requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  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: Favorable

 
We decided that the Plan has 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 that an alternative to skilled nursing facility, the enrollee may 
benefit from custodial care nursing home stay with Part B therapy services 2-3 times per week. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows the enrollee requires frequent lab draws, pain and 
wound management thus would be expected to require frequent assessment by skilled nursing thus daily skilled 
services are supported.  
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hand finger orthosis (L3913) provided on May 5, 2023. 
 
You asked the Plan to pay for a hand finger orthosis. You say that you are requesting reconsideration for 
services, advising this is a valid diagnosis for the procedure performed. The Plan denied your request. The Plan 
says two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M24.542 has an Excludes1 note in relation to M72.0. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for a hand finger orthosis have not been met. Therefore, we decided that the Plan does not have to 
pay for a hand finger orthosis (L3913) provided on May 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 inpatient rehabilitation would be better than a skilled 
nursing due to multitude of the enrollee's comorbidities. The Plan denied your request. The Plan says the 
enrollee's records do not show rehabilitation needs are complex. The Plan says services may be provided at a 
lower level of care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 14, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on January 25, 2023, billed with 
procedure code G0453. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that this service requires a qualifying service be 
received and covered. 
 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 G0453 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for testing services provided on January 25, 2023, billed with procedure code G0453.