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

 
We decided that the Plan has to pay for the long-term care hospital (LTCH) stay on dates of service March 30, 
2023, through June 26, 2023. 
 
You asked the Plan to pay for the LTCH stay. You say that LTCH stay should be paid as billed because it was 
coded accurately. The Plan denied your request. The Plan says that the LTCH stay is denied because it is 
bundled with the previous LTCH stay and is not considered a separate admission. 
 
The Plan must follow Medicare rules. Medicare rules say that when an enrollee at a LTCH is admitted upon 
discharge to an inpatient acute care hospital and their stay at the inpatient acute care hospital exceeds the 9 
consecutive day threshold, the return to the LTCH is a new admission.  
 
We looked at the file and Medicare rules. Records in this case indicate that the enrollees first LTCH stay was 
from March 16, 2023, to March 21, 2023. The discharge code assigned on the LTCH claim for March 16, 2023, 
to March 21, 2023, is 02, indicating the enrollee was discharged to a general acute care hospital. Records also 
indicate that the enrollee returned to the LTCH on March 30, 2023. As the day count away from the LTCH 
begins on the discharge date from the LTCH and ends on the day of readmission, this enrollee was away from 
the LTCH for a total of 10 consecutive days from March 21, 2023, through March 30, 2023. As such, the return 
to the LTCH on March 30, 2023, is considered a new admission. Based on this information, we decided that 
Medicare rules for coverage of the LTCH stay have been met. Therefore, we decided that the Plan has to pay 
for the long-term care hospital (LTCH) stay on dates of service March 30, 2023, through June 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine panel provided on June 26, 2023. 
 
You asked the Plan to pay for the urine panel. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine panel provided on June 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's health is at risk and needs to regain 
enough strength and ability to be independent to return home. The Plan denied your request. The Plan says the 
records do not show the enrollee requires continued daily skilled nursing or skilled therapy in a SNF setting. 
The Plan says services needed are called custodial care. 
 
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 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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alginate dressing (A6196) and non-waterproof tape (A4450) 
provided on November 28, 2022. 
 
You asked the Plan to pay for alginate dressing and non-waterproof tape. You say that the services were billed 
correctly. The Plan denied your request. The Plan says the billed services were paid already as part of the 
inpatient skilled nursing facility claim. 
 
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 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 alginate dressing and non-waterproof tape. Our reviewer says 
that the services are not supported. Our reviewer found medical records do not support the codes to be billed 
again outside of the Skilled Nursing Facility bill. Codes A4450 and A6196 have been paid and processed and do not meet the requirements to be billed again with Point of Service (POS) 32. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of alginate dressing and non-waterproof tape have not been met. Therefore, we 
decided that the Plan does not have to pay for alginate dressing (A6196) and non-waterproof tape (A4450) 
provided on November 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiogram provided on June 16, 
2023. 
 
You asked the Plan to waive the copayment for the echocardiogram. You say that you are not willing to pay the 
amount billed for the 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 $120 
copayment for other in-network Medicare-covered radiological diagnostic services.  
 
 You have been asked to pay a $120 copayment for the echocardiogram. This item/service falls within the 
outpatient diagnostic tests and therapeutic 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 echocardiogram provided on June 16, 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 you require a short stay in a rehabilitation hospital to 
regain your strength in order to be independent at home again. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, but skilled therapies 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 your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the standard wheelchair (K0001) and sales tax 
(S9999) purchased October 13, 2022. 
 
You asked the Plan to reimburse you for the wheelchair. You say that you were confined to a rehab facility 
following abdominal wheelchair. A wheelchair was required at the facility and the rehab facility would not 
authorize discharge unless such DME was available at home. The Plan denied your request. The Plan says the 
purchase of a wheelchair and sales tax are not covered under any normal circumstances. The plan only covers 
the rental of a wheelchair. 
 The Plan must follow Medicare rules. The rules say that that Medicare pays for most DME on a rental basis. 
 
We looked at the file and Medicare rules. Wheelchairs are a rental only item and sales tax is not covered.  
Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. 
Therefore, we decided that the Plan does not have to reimburse you for the standard wheelchair (K0001) and 
sales tax (S9999) purchased October 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test and a specialist 
office visit provided on August 22, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test and a specialist office visit. 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 $35 
copayment for outpatient diagnostic tests/X-rays and a $45 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a $35 copayment for an outpatient diagnostic test and a $45 copayment for a 
specialist office visit. However, since the allowed amount is less than the standard copayment for the X-ray, 
you only owe $32.39. The total amount you are being asked to pay is $77.39. This item/service falls within the 
outpatient diagnostic tests/X-rays and physician/practitioner services/specialist 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 outpatient diagnostic test and a specialist office visit provided on 
August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with multiple 
power options (K0862) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2363, E2377, E2608, E2621, and K0040). 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair and additional items and 
accessories. You say that the enrollee continues to have repeated falls that are putting them at risk for 
additional injury. You also say that the requested power mobility device would reduce/eliminate their falls. The 
Plan denied your request. The Plan says the enrollee does not have medical need for multiple power options 
available with a K0862 Group 3 power wheelchair. The Plan also says an expandable controller, harness and 
electronics are not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0862) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 heavy duty power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found in this case, the enrollee has a neurologic disorder with functional deficits. The 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Our reviewer found 
that although the enrollee's condition may meet criteria for a power wheelchair, the criteria for this specifically 
requested power wheelchair are not met. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 heavy duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy duty 
power wheelchair with multiple power options (K0862) and additional items and accessories (codes E0955, 
E1007, E1012, E1028, E2311, E2313, E2363, E2377, E2608, E2621, and K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service July 24, 
2023. 
 
You asked the Plan to pay for procedure code 99253. You say that the claim should be paid. 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 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service July 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay following an elective right reverse 
shoulder arthroplasty with distal clavicle resection (codes 23472-RT and 23120-RT). 
 
You asked the Plan to pay for an inpatient hospital stay. You say that if the patient does not meet inpatient 
criteria, to back the case down as outpatient. The Plan denied your request. The Plan says the patient does not 
meet the requirement for approval. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 an inpatient hospital stay. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation did not describe the patient with an unstable condition or 
high-risk medical history to expect that they might require inpatient services that would likely cross 2 
midnights. Our reviewer also found that the planned procedure is not listed on the Centers for Medicare & 
Medicaid Services (CMS) inpatient only list.  
 
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 inpatient hospital stay have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient hospital stay following an elective right reverse shoulder arthroplasty 
with distal clavicle resection (codes 23472-RT and 23120-RT).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99285) provided on May 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making". 
 
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 use of code 99285 is not supported by the records provided. Our reviewer found that there is no documentation supporting a high 
level of medical decision-making. 
 
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 the emergency care (99285) provided on May 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99223 billed for date of service March 10, 2023. 
 
You asked the Plan to pay for 99223. You say that 99223 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99223 is denied because it is not supported in the 
documentation. 
 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 99223. Our reviewer says that 99223 is not 
supported in the documentation. Our reviewer found this case pertains to a 68-year-old with atrial fibrillation, 
pulmonary hypertension, aortic insufficiency, and heart failure who was admitted to the hospital for 
palpitations and shortness of breath. Documentation does not support a high level of medical decision making, 
nor is there evidence of at least 75 minutes of time spent performing this service. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99223 billed for date of service March 10, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
April 5, 2023, to April 26, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of PCDs have not 
been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from April 5, 2023, to April 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomographic angiography (CTA) 
chest provided on June 06, 2023. 
 
You asked the Plan to waive the copayment for computed tomographic angiography (CTA) chest. You say that 
you should not have copayments this high and the bills didnt start coming in until August/September. 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 $125 
copayment for advanced radiology diagnostic services. 
 
You have been asked to pay a $125 copayment for computed tomographic angiography (CTA) chest. This 
item/service falls within the advanced radiology diagnostic 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 computed tomographic angiography (CTA) chest provided on June 06, 2023.