Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the request is not medically necessary because the records show that 
the ordered settings for the noninvasive ventilator show it is going to be used only in a bi-level pressure 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD/asthma 
overlap with frequent exacerbations. The enrollee also has severe obesity, obstructive sleep apnea, coronary 
artery disease, and atrial fibrillation. The most recent clinical visit is dated August 10, 2023, and notes that the 
enrollee is on "as-needed home ventilator". The records do not include any compliance download data. An 
arterial blood gas on December 14, 2023, with the enrollee on BiPAP, showed very mild acute-on-chronic 
carbon dioxide retention. It is unclear whether the enrollee was acutely ill at the time of this blood gas. The 
orders indicate the ventilator is to provide a volume assurance mode, which can be provided with BiPAP. There 
is no diagnosis of thoracic restrictive disease or neuromuscular disease. Pulmonary function tests in 2021, show 
combined obstructive and restrictive lung disease, with a forced expiratory volume (FEV1) of 41% of 
predicted. This enrollee may benefit from BiPAP with volume assurance. The records do not show this has 
been tried and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can 
be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 rendered on August 7, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records are not supported as Prolia is not a complex drug. 
 
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 96401 is "Chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the description of the services in 
the records is not inherently highly complex and nothing in the provided medical records in this case describes special considerations for preparation, dosage or disposal, frequent changes in infusion rate, prolonged nursing 
presence or frequent conferring with the physician as are described in the CPT codebook as examples of a 
highly complex drug administration. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 96401 rendered on August 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from June 1, 
2023, to June 6, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
We find that the home health services at issue do not meet criteria for payment. Specifically, the services have 
been reported without a required G code to represent a visit by the appropriate HH care discipline(s). 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 pay for home health services billed for dates of service 
from June 1, 2023, to June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HDR electronic brachytherapy. 
 
You asked the Plan to pre-approve HDR electronic brachytherapy. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are 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 HDR electronic brachytherapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has basal cell carcinoma of the right forehead. The 
documentation does not support that electronic brachytherapy is medically necessary. Therefore, the enrollee 
does not meet criteria for the requested 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 HDR electronic brachytherapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve HDR electronic brachytherapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this test provides valuable information for 
physicians to use in determining appropriate treatments. 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 laboratory services 
provided on August 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee can receive personalized 
treatment and has the best chance at recovering at the LTACH. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care and is unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the health Plan. The documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
12, 2023.  
 You asked the Plan to pay for procedure code 86077. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 24, 2023 to August 
22, 2023. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the home health services are not supported in the medical record. Specifically, the date on the 
notice of admission does not match the admission date on the claim. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided on July 24, 2023 to August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit and the advance care planning 
provided on July 31, 2023. 
 
You asked the Plan to pay for the annual wellness visit and the advance care planning. 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 annual wellness visit 
and the advance care planning provided on July 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular stress test provided on January 27, 2023. 
 
You asked the Plan to pay for the services. You say that the date of service is comparable with the code billed. 
The Plan denied your request. The Plan says the diagnosis code was not appropriate. 
 
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 93015 is "Cardiovascular stress test using maximal or 
submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report." 
 
CPT 93015 was billed with diagnosis code I48.91 - unspecified atrial fibrillation. 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 a cardiovascular stress test provided on January 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services. You asked the Plan to pre-
approve home health services. You say that  the requested home health services 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 that the 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee has been educated on their disease process and medications. No medical notes from the 
enrollee's treating physician are provided documenting a need for additional skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRA of the abdomen (74185). 
 
You asked the Plan to pre-approve an abdominal MRA. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs must be reasonable and necessary for the 
diagnosis or treatment of the specific patient involved.  
 
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 an abdominal MRA. Our reviewer says 
that an abdominal MRA is not medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation does not support the medical necessity of MR angiography. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an abdominal MRA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRA of the abdomen (74185).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on February 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0428 and A0425 provided on June 19, 
2023. 
 
You asked the Plan to pay for procedure codes A0428 and A0425. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the diagnosis code at issue is 
not appropriate as a primary diagnosis. 
 The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I31.4. This code is 
not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes A0428 and A0425 
provided on June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37225 rendered on August 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 37225 is not supported by the records submitted. 
 
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 37225 is "Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same 
vessel, when performed." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation is not sufficiently clear to confirm that the procedure in question as indicated by CPT code 37225 was rendered. The 
details of post intervention results were too vague on which to determine that meaningful atherectomy was 
performed. The notation of a post stent angiogram further adds to the lack of clarity as, if a stent was placed, a 
different code would be used. Details are provided of pre intervention intravascular ultrasound (IVUS) results, 
but no post intervention IVUS results are documented. If applicable, failed procedures are not separately 
billable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 37225 rendered on August 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on June 23, 2023. 
 
You asked the Plan to waive the copayment for an x-ray. You say that the x-ray should be included with the 
office visit. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an x-ray provided on June 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan, heart 
provided on June 30, 2023. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan, heart. You say that you 
spoke to member services and were told the CT scan was 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 a $250 
copayment for Outpatient diagnostic tests and therapeutic services and Prior authorization rules supplies. 
 
You have been asked to pay a $250 copayment for computed tomography (CT) scan, heart. This item/service falls within the Outpatient diagnostic tests and therapeutic services and Prior authorization rules supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
However, since the allowed amount is less than the standard copayment, you only owe $119.23. Therefore, we 
decided that the Plan does not have to waive the copayment for computed tomography (CT) scan, heart 
provided on June 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 26, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that no services were 
provided. 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on July 26, 2023.