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

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service January 18, 
2023.  You asked the Plan to pay for procedure code 88374. You say that the lab reports validate the number of units 
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 code 88374 is 5. The MAI value for this code is 3. You billed 10 units of this 
code, exceeding the MUE. The documentation does not show why the excess units were medically necessary. 
Based on this information, we decided that Medicare rules for coverage of procedure code 88374 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 88374 billed for date of 
service January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on March 8, 2023, and billed with codes 87481, 87150, 87640, 87653, and 87798. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on March 8, 2023, and billed with codes 87481, 87150, 87640, 87653, and 87798.
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 to go into therapy to get strong 
enough to go home. You say the support from the IRF will improve the enrollee's mobility to get back to 
baseline. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting have not 
been met.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for each light therapy service provided from 
December 5, 2022, to March 15, 2023. 
 
You asked the Plan to waive the copayments for each light therapy service. You say that this should be covered 
under your Plan. 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 2022 contract with the Plan clearly says that you must pay a 
$50 copayment for specialist services. Your 2023 contract with the Plan clearly says that you must pay a $45 
copayment for specialist services. You have been asked to pay $29.01, which is less than the standard $50 copayment for each light therapy 
service provided from December 5, 2022, to December 28, 2022. You have also been asked to pay $29.44, 
which is less than the standards $45 copayment for each light therapy service provided from January 4, 2023, 
to March 15, 2023. This item/service falls within the physician/practitioner 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 copayments for each light therapy service provided from December 5, 
2022, to March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 22, 
2023.  You asked the Plan to pay for procedure code 99458. You say that this is a Medicare covered service. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 code 99458 is 3. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. The documentation provided does not clearly document why the excess units were 
needed. Based on this information, we decided that Medicare rules for coverage of procedure code 99458 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99458 billed for 
date of service February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs this equipment to safely stay out 
of the hospital. The Plan denied your request. The Plan says this ventilator was ordered in settings that could be 
delivered by a bilevel positive airway pressure (BiPAP) machine with average volume-assured pressure support 
(AVAPS) mode. 
 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. 
 
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 ventilator. Our reviewer says that the 
enrollee does not meet criteria for a ventilator. Our physician reviewer found the enrollee has chronic 
respiratory failure from chronic obstructive pulmonary disease (COPD). The primary source documentation 
does not contain sufficient detailed information in the medical records to justify the selected treatment. The 
enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume-
assured pressure support (AVAPS) mode and failure of such a device has not been documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor.  
You asked the Plan to pre-approve the Dexcom G6 sensor. You say that you have tried a regular glucometer 
(Livongo), however, the finger stick is not working for your due to your age and it is very painful. The Plan 
denied your request. The Plan says you do not meet the criteria because you are not on any medications for 
treatment of your diabetes. 
 
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 Dexcom G6 sensor. Our reviewer 
says that the Dexcom G6 sensor is not medically necessary. Our physician reviewer found you have been 
checking blood glucose sugar in October of 2022 and it is unclear why you say that a glucometer would not 
suffice for you at this time. The criteria for the CGM coverage include insulin use or low blood glucose sugar. 
You have neither so CGM 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 Dexcom G6 sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 sensor.
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 IRF care is medically necessary for the enrollee 
to return home at his maximum level of functioning with decreased risk of re-admission. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility, home with home health services, or home with outpatient 
therapy. 
 
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 was admitted for altered mental status, hypoglycemia, and hypotension. 
The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair (K0823). 
 
You asked the Plan to pay for a power wheelchair. You say that the item should be covered. The Plan denied 
your request. The Plan says you may not balance bill the patient unless you have a written agreement to do so 
prior to the services being performed.  
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power wheelchair have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to pay for the power wheelchair (K0823).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service November 
21, 2022.  You asked the Plan to pay for procedure code 88374. You say that the lab reports validate the number of units 
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 code 88374 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. In this case, the medical records do not clearly document the need for the excess 
units provided. Based on this information, we decided that Medicare rules for coverage of procedure code 
88374 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88374 
billed for date of service November 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132 x2, 96133 x10). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says a neurobehavioral status exam has not been completed. 
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on review of the documentation presented, it is difficult to see how 
the current neuropsychological testing would be used to help treatment and is therefore not considered to be 
reasonable or medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96132 x2, 96133 x10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99310). 
 
You asked the Plan to pay for the nursing facility care. You say that the services should be covered. The Plan 
denied your request. The Plan says  it is the providers responsibility to bill the Primary Group Health Plan or 
any liability insurance before submitting the claim to the members plan.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The Plan has 
directly communicated with the provider that the primary insurer must be billed first.. As the secondary insurer, 
the Plan cannot be held responsible for the nursing facility care until the primary insurer has denied the claim 
for these services. Therefore, we decided that the Plan does not have to pay for the nursing facility care 
(99310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit on January 04, 2023. 
 
You asked the Plan to waive the coinsurance for an office 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 50% 
coinsurance of the Medicare-allowed amount for primary care provider office or telehealth visit for Medicare-
covered services. Covered services include medically necessary medical care or surgery services furnished in a 
physicians office, certified ambulatory surgical center, hospital outpatient department, or any other location 
including telehealth. The allowed amount is $141.49 The plan paid $70.75 and applied a $70.74 coinsurance. 
$141.49 - $70.75 = $70.74. Therefore, results in the total cost sharing amount of $70.74. You have been asked to pay a $70.74 coinsurance for an office 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 coinsurance for an office visit on January 04, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator system for 
treatment of central sleep apnea (CSA) (0424T). 
 
You asked the Plan to pre-approve insertion or replacement of neurostimulator system for treatment of central 
sleep apnea. You say that this is medically necessary. The Plan denied your request. The Plan says the use of 
phrenic nerve stimulation for central sleep apnea is considered investigational and therefore not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion or replacement of 
neurostimulator system for treatment of central sleep apnea. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested 
service/device is experimental in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of neurostimulator system for treatment of central 
sleep apnea have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or 
replacement of neurostimulator system for treatment of central sleep apnea (CSA) (0424T).
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 services are medically necessary.  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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on December 16, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service billed is supported in the records. The 
Plan denied your request. The Plan says that enrollees must receive their care from a network provider. 
 
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. The Plan did not provide the complete 2022 Evidence of Coverage (EOC). 
Therefore, we decided that the Plan has to pay for the office visit provided on December 16, 2022, by an out-
of-network (OON) provider.  
 
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.