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

 
We decided that the Plan does not have to pay for laboratory services (87801) provided on March 29, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says out-of-network services are covered only in certain 
limited circumstances which have not been met in this case. These services were not performed or referred by a 
network provider. 
 
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 (87801) provided on March 
29, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 provided on March 10, 2023. 
 
You asked the Plan to pay for procedure code 99239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is Hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of discharge management services provided on March 10, 2023. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99239 provided on March 10, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 and L5 kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve T12 and L5 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because the records do not show evidence of 
an L5 vertebral compression fracture on either of the radiographic studies provided. Additionally, the 
radiographic studies show that there is retropulsion/canal compromise associated with the T12 compression 
fracture, which is a relative contraindication to percutaneous vertebroplasty. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 T12 and L5 kyphoplasty. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation 
is not evident regarding a progression of the body height loss at both T12 and L5, greater than 25% vertebral 
body height loss at L5, kyphotic deformity, or a severe impact on daily activities. Moreover, there is magnetic 
resonance imaging corroboration of retropulsion and other plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 and L5 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T12 and L5 kyphoplasty (22513, 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) month use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve additional use of a home ventilator. You say that you are requesting 
reconsideration and have provided medical records for review. The Plan denied your request. The Plan says the 
request for continued use of a ventilator is not medically reasonable and necessary. 
 
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 additional use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
hospitalized in January 2023, with pneumonia, cellulitis, exacerbation of diastolic heart failure, and arterial 
blood gas (ABG) consistent with acute on chronic hypercarbic respiratory failure. The enrollee has obstructive 
sleep apnea previously treated with CPAP. There is class IV obesity. COPD is mentioned in one note, but not 
listed on the admission diagnoses, and there are no pulmonary function tests. There is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. This enrollee has obesity hypoventilation syndrome and may 
benefit from BiPAP with average volume assured pressure support (AVAPS) during sleep as an outpatient. 
Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or 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 continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nine (9) month use of a home ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automated logistics systems (ALS) intercept services 
received on February 4, 2023.  
 
 You asked the Plan to pay for the ALS services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says they confirmed the ALS paramedic intercept did not transport and the 
services did not occur in a rural area. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that this provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the advanced life support (ALS) intercept services received on February 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a trial and 
failure of a back brace for fracture care. The criteria for coverage are not met and the kyphoplasty is not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve OON acupuncture treatments. You say that the in-network providers are 30-
40 mins away and your provider is only two blocks from your house. The Plan denied your request. The Plan 
says in-network providers are available. 
 
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 
acupuncture treatments to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 13, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
advised there would be a copayment applied. 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 $175 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $175 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 a 
computed tomography (CT) scan provided on March 13, 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 the enrollee meets the admission criteria for 
admission to an IRF, and it i expected that the enrollee, through an integrated multidisciplinary approach to 
rehabilitation, will be able to regain their maximum level of function in the shortest amount of time. The Plan 
denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 enrollee's 
medical problems are stable. 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 therapy  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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 26, 2023, to 
February 24, 2023. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA.  
You said that you were not aware that the Plan was following the 5-day rule for NOAs. The Plan denied your 
request. The Plan says the NOA was not received timely. 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 start of care date is October 28, 2022. The NOA was not received by the Plan until March 27, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, 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 January 26, 2023, to February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer covering and prosthetic donning 
sleeve for a lower limb prosthesis. 
 
You asked the Plan to pre-approve protective outer covering and prosthetic donning sleeve. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says there is no documented 
need for extra protection for the prosthesis, and a prosthetic donning sleeve is not covered by Medicare. 
 
The Plan follows Medicare rules. Medicare rules state that protective outer surface coverings are intended for 
enrollees with special needs for protection against unusually harsh conditions that require protection beyond 
what is afforded by a standard covering. Medicare rules state that prosthetic donning sleeves 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 protective outer covering and prosthetic 
donning sleeve. Our reviewer says that the enrollee does not meet criteria for a protective outer covering. Our 
physician reviewer found the records do not show that the enrollee will be exposed to unusually harsh 
conditions or activities for which a standard prosthetic covering would be inadequate. 
 
Furthermore, the requested prosthetic donning sleeve is not covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of protective outer covering and prosthetic donning sleeve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a protective outer covering and prosthetic 
donning sleeve for a lower limb prosthesis.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 97530 billed for dates of service March 1, 2023, to 
March 29, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the 
documentation does not include a plan of care and short-term goals. 
 
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 CPT code 97530 was billed with a GP modifier on each date at issue. The records provided do 
include a plan of care provided on February 20, 2023. The plan of care includes the recommended treatment, 
treatment goals, and a frequency of 2 to 3 times per week for 4 to 6 weeks. Based on this information, we 
decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the 
Plan has to pay for procedure code 97530 billed for dates of service March 1, 2023, to March 29, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each computed tomography (CT) scan 
provided on November 10, 2022, to November 22, 2022. 
 
You asked the Plan to waive the copayment for each computed tomography (CT) scan. You say that you feel 
you should only owe one copayment for the same service. 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 $150 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for each computed tomography (CT) scan. This item/service 
falls within the outpatient diagnostic tests 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 total you owe is $300 for CT scans provided on November 10, 2022, 
and November 22, 2022 ($150 per scan x 2 scans = $300). Therefore, we decided that the Plan does not have to 
waive the copayment for each computed tomography (CT) scan provided on November 10, 2022, to November 
22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the orthotic device provided on March 29, 
2023. 
 
You asked the Plan to waive the coinsurance for the orthotic device. You say that this should be under durable 
medical equipment and have 0% coinsurance. 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 in-network prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the orthotic device. This item/service falls within the in-
network prosthetic devices and related 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 
coinsurance for the orthotic device provided on March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH 
services in order to regain a maximum level of functioning. The Plan denied your request. The Plan says that 
the request is not medically necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has multiple active complex medical issues including an unstable pulmonary 
status with slow improvement towards weaning from ventilator support. It is clear from the documentation 
provided that inpatient services are appropriate and necessary and would likely be required in the range of 25 
additional days. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee has limited endurance, is weak and is 
balance impaired. You also say the enrollee has impulsivity and decreased safety insight. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in a SNF.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.