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

 
We decided that the Plan does not have to pay for the office visit (99203) provided on November 30, 2022. 
 
You asked the Plan to pay for the office visit (99203). You say that the service should be covered. 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 office visit (99203) 
provided on November 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 
9, 2022, to March 28, 2022, as the billed Health Insurance Prospective Payment System (HIPPS) rate code. 
 
You asked the Plan to pay for SNF care at the rate code billed. You say that these services were medically 
necessary and are supported as billed. The Plan denied your request. The Plan says the HIPPS rate code billed 
is not supported in the medical records provided; the clinical documentation does not support coding of 
parenteral intravenous (IV) feeding while not a resident as there is no evidence provided to support an 
additional need for IV intake specifically addressing a nutrition or hydration need. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate HIPPS code. 
 
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 SNF care at the rate code billed. Our 
reviewer says that the rate code billed is not supported. Our physician reviewer found that the documentation 
provided is insufficient to support that any SNF services were medically necessary, reasonable, and provided as 
billed. There is no evidence to support the billing of parenteral nutrition while not a resident. Therefore, the 
Plans denial 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 SNF care at the rate code billed have not been met. Therefore, we decided that 
the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 9, 2022, to 
March 28, 2022, as the billed Health Insurance Prospective Payment System (HIPPS) rate code.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (97530, 97166, 97535) 
provided on June 19, 2023. 
 You asked the Plan to pay for occupational therapy services. You say that you have billed the services at issue 
correctly. 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 F04.B0, defined 
as Vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and 
anxiety. This code is not an appropriate primary diagnosis as the code category 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 occupational 
therapy services (97530, 97166, 97535) provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says the notes 
do not say that you will be able to use the power wheelchair for use in your home to take care of your basic 
needs on a daily basis. The Plan also says that this request cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power wheelchair. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found you have obesity and impaired 
ambulation but are able to manage household ambulation. Our reviewer also found that you do not require a 
powered wheelchair to manage mobility related self-care in the home. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 29, 
2023. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient hospital services/lab services. 
 
You have been asked to pay a $40 copayment for laboratory services. This item/service falls within the 
outpatient hospital services/lab 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 laboratory services provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 93010 billed for date of service 
January 3, 2023.  
 
You asked the Plan to pay for procedure codes 93042 and 93010. The Plan denied your request. The Plan says 
payment for codes 93042 and 93010 is bundled. 
 
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 93042 
is a column two code to column one code 99291 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. We have also 
confirmed that code 93010 is a column II code to column I code 31500. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 93042 and 93010 billed for 
date of service January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns (D6058), a core build-up 
(D2950/D2954), and pontics (D6245). 
 
You asked the Plan to pre-approve D6058, D2950, D2954, and D6245. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says this dental work has been processed 
correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported crowns (D6058), a core build-up (D2950/D2954), and pontics (D6245).
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 cannot walk 3 steps, sit up, or stand without 
assistance. The Plan denied your request. The Plan says that you can receive the necessary care in a different 
setting.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF.  
 
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 pre-approve neurosurgery consultation and treatment to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON neurosurgery services. You say that you have been seeing this 
provider previously, and he did your prior surgery. You received advanced imaging based on his order this year 
and do not trust any other surgeon to provide your care.  The Plan denied your request. The Plan says you saw 
this OON provider without authorization in October 2023, but there are network neurosurgeons who can 
provide the ongoing care you require.  
 
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 
neurosurgery consultation and treatment 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 genetic testing provided on August 3, 2023. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 13, 
2023. 
 You asked the Plan to pay for procedure code 81456. 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. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 17, 2023, to June 
13, 2023. 
 You asked the Plan to pay for the home health services. You say that these are covered, billable services. The 
Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from May 17, 
2023, to June 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service August 1, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that the enrollee was seen twice on the same date 
of service. The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for 
code 99285. 
 
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 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on July 17, 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 services were not urgent or emergent and were processed correctly. 
 
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 laboratory services rendered on July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Mis Sensor.  
You asked the Plan to pre-approve a Dexcom G7 Mis Sensor. The Plan denied your request. The Plan says the 
patient does not meet the criteria for coverage. 
 
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 patient has not been diagnosed 
with pre-diabetes, does not use insulin, or have a history of problematic hypoglycemia. Based on this 
information, we decided that Medicare rules for coverage of a Dexcom G7 Mis Sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 Mis 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show the enrollee needs the intensity of an 
inpatient rehabilitation or full time access to a physician or skilled rehabilitation nurse. The Plan says needs can 
be met at an alternate level of care to help with mild decline in general function.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: 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 would like to go to the rehabilitation hospital. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies 
as an outpatient or at a skilled nursing facility (SNF) may be approved upon request.  
 
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. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do 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. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
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.