Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 97010 billed for date of service January 3, 
2023 to January 31, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 97010 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service January 3, 2023 to January 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment physical therapy provided on January 12, 
2023, to January 13, 2023. 
 
You asked the Plan to waive the copayment physical therapy. You say that you disagree with these charges. 
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 $15 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $15 copayment for physical therapy. This item/service falls within the outpatient 
rehabilitation services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. The self-administered drugs provided (A9270) are not a covered benefit. The amount you are being asked to pay for A9270 is $15. The total amount you are being asked to pay is $30 ($15 
+ $15 = $30). 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 physical therapy provided on 
January 12, 2023, to January 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 14, 2022, to 
April 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
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 March 14, 2022. The NOA was not received by the Plan until jUNE 9, 
2022. 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 March 14, 2022, to April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 26, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile, nonimpregnated gauze (A6402) foam dressing 
(A6212) non-waterproof tape (A4550) and alginate or other fiber gelling dressing (A6196) provided September 
2, 2022, to September 16, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that you are sending this dispute letter for 
review of proof of delivery documents. You have uploaded the delivery confirmation documents. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The records do not include a valid physician 
order and the supplier did not provide office notes to support the subsequent ordering of wound care products. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the sterile, nonimpregnated gauze (A6402) foam 
dressing (A6212) non-waterproof tape (A4550) and alginate or other fiber gelling dressing (A6196) provided 
September 2, 2022, to September 16, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met in 
another 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 enrollee is medically stable and does not need physician supervision three 
times a week in the IRF. There is no current medical complexity. There are no acute rehab nursing needs 
documented. The enrollee does not need specialized and intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The complexity of the 
enrollee's nursing, rehab, and medical, needs (combined complexity) does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollee's rehab needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility (SNF). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services provided on 
March 7, 2023. 
 
You asked the Plan to waive the copayment for the ophthalmological services. You say that your routine eye 
exam should be free once per year. 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 $15 
copayment for a routine eye exam. 
 
You have been asked to pay a $15 copayment for the ophthalmological services. This service falls within the 
vision care 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 ophthalmological services 
provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on  
February 2, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that the annual wellness visit should be 
covered with $0 member responsibility. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. The medical record showed that the provider discussed chronic problems that are 
not part of the annual wellness. The claim was charged as an annual wellness, which is a covered benefit with 
no copayment amount however they also added an office visit charge to the claim. 
 
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 physician/practitioner services, including doctor's office visits.  
 You have been asked to pay a $20 copayment for the office visit. This service falls within the 
physician/practitioner services, including doctor's 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 copayment for an office visit provided on February 2, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 8, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the member did not tell you that she had 
switched from traditional Medicare to the Plan. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by an in-network doctor. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023, to February 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fosfomycin. 
 
You asked the Plan to pre-approve fosfomycin. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve fosfomycin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device. 
 
You asked the Plan to pre-approve Cala Trio device. You say that this device is vital and beneficial treatment 
for the enrollee. The Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that electric nerve stimulation to treat motor function 
disorders is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Cala Trio device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Cala Trio nerve stimulator device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet light therapy unit. 
 
You asked the Plan to pre-approve ultraviolet light unit. You say that this treatment is recommended. The Plan 
denied your request. The Plan says the documentation does not indicate a diagnosis of generalized psoriasis and 
this device is being requested for the convenience of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that ultraviolet therapy units are covered for selected 
patients with generalized intractable psoriasis.  
 
We looked at the file and Medicare rules. The documentation does not support a diagnosis of generalized 
intractable psoriasis. Based on this information, we decided that Medicare rules for coverage of ultraviolet light 
unit have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet light 
therapy unit.
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 it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
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. You were 
admitted for congestive heart failure and frequent falls and was discharged home on June 14, 2023. Medical 
problems are stable. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid-circulating cold pad (code E0218) you received on 
March 31, 2023. 
 
You asked the Plan to pay for the fluid-circulating cold pad. You say that this item was needed because you 
tried using ice packs, but they did not work for you. You said that you used this machine when you had surgery 
on your left knee in 2019, and this item helped you a lot then. The Plan denied your request. The Plan says this 
item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that fluid-circulating cold pads with pump 
(E0218) are not covered because they are considered not reasonable and necessary.  This means that this item 
cannot be covered. We looked at the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the fluid-circulating cold pad have not been met. Therefore, we decided that the 
Plan does not have to pay for the fluid-circulating cold pad (code E0218) you received on March 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 billed for date of service November 
14, 2022. 
 You asked the Plan to pay for procedure code 93306. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93306 is bundled into payment for code 
33361. 
 
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 93306 
is a column II code to column I code 33361. 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 93306 billed for date of service November 14, 
2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met at an 
alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physician supervision three 
times a week in an IRF. There are no acute rehab nursing needs documented. The enrollee needs routine 
physical and occupational therapy. The complexity of the enrollee's nursing, rehab, and medical, needs 
(combined complexity) does not require an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitative care. The enrollee's current functional level requires prolonged rehabilitation in an 
alternate and low intensity setting such a skilled nursing facility (SNF).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram, routine (93010) provided October 30, 2021. 
 
You asked the Plan to pay for the emergency services. You say that please review the attached, showing proof 
of your due diligence to meet these filing requirements and override the denial. The Plan denied your request. 
The Plan says the claim was submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency services was not filed until March 14, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit (99285) and electrocardiogram, 
routine (93010) provided October 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.