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

 
We decided that the Plan does not have to pay for a closed treatment of proximal humeral (surgical or 
anatomical neck) fracture; without manipulation (23600) provided on June 29, 2022. 
 
You asked the Plan to pay for surgery services. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says code 23600 remains 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. 
 
 
 
 
 
 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 surgery services. Our reviewer says that the service does not 
meet criteria for payment on this claim. Our reviewer found medical record does not include sufficient 
documentation to support treatment of humeral fracture. Procedure report describes, the enrollee presented to 
the emergency department for constipation. Then returns to emergency department for rehab consideration. 
Examination of musculoskeletal "Left arm sling".  Radiology impressions "Closed displaced fracture 
morphology, initial encounter".  Medical decision making (MDM) documents physical therapy (PT) 
occupational therapy (OT) consultation and case management. In this case, confirmation cannot be made of 
fracture treatment provided during this visit, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery services have not been met. Therefore, we decided that the Plan does 
not have to pay for a closed treatment of proximal humeral (surgical or anatomical neck) fracture; without 
manipulation (23600) provided on June 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 23, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee has age 
related weakness and is fall risk. You also say that due to this condition any other means of transport would be 
unsafe. The Plan denied your request. The Plan says the ambulance transportation from the hospital to the 
enrollee's assisted living facility was not medically necessary.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance service and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the emergency department to the 
enrollee's living facility was not medically necessary. The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. A prudent person would not believe that immediate medical 
attention was required for someone who was being discharged from the emergency department. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on April 23, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and the supply allowance 
 
You asked the Plan to pre-approve the CGM and supply allowance. You say that you are appealing the denied 
CGM. The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Phone call logs are not an acceptable substitution for medical records. 
Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and the supply 
allowance  
 
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: 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 are requesting an expedited reconsideration as 
the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says criteria for 
admission to the acute IRF setting have not been met.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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 pay for initial hospital care (procedure code 99223) rendered on May 
4, 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 denied code remains 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 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 coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records do not support this level of 
coding. The provided records in this case do not document 2 out of 3 of an extensive number of diagnoses or 
management options, an extensive amount and complexity of data reviewed and high risk of complication. 
Therefore, the records do not support a high level of medical decision making. The records do not document 
that 75 minutes or more of time was spent on this service. 
 
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 initial hospital care (procedure code 99223) rendered on May 4, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87481 x4. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 87481 x1.   

You asked the Plan to pay for procedure code 87481 x5 provided on November 3, 2022. You say that you 
would like the Plan to reconsider their denial of payment. The Plan says that the laboratory results only support 
4 units of procedure code 87481. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87481 x4.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 4 units of CPT code 87481 are supported in the medical record. Based on this information, we 
decided that Medicare rules for coverage of 4 units of CPT code 87481 have been met. Therefore, we decided 
that the Plan has to pay for the services described by procedure code(s) 87481 x4.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 87481 
x1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 5 units of CPT code 87481 are not supported in the medical record. The medical record only 
supports 4 units of CPT code 87481. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code(s) 87481 x1. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 8, 2023, to April 
6, 2023. 
 You asked the Plan to pay for the home health services. You say that the required NOA was submitted. 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 February 6, 2023. The NOA was not received by the Plan until June 14, 
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 March 8, 2023, to April 6, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you the full amount minus your applicable copayment for urgent 
care/clinic services provided on January 27, 2023. 
 
You asked the Plan to reimburse you the full amount for the urgent care/clinic services. You say that you fell 
while on vacation in Hawaii and the third place you went to was urgent care that agreed to see you but you had 
to pay $1,465.09 in advance for treatment for your fractured elbow. You say that you disagree with the 
reimbursement of $299.93 you received from the Plan and you are requesting full reimbursement. The Plan 
denied your request. The Plan says that this provider is not participating with Medicare and has no obligation to 
accept the CMS assignment. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans must pay for emergency and urgently 
needed services. Medicare rules also say that Plans must disclose to its enrollees any conditions or limitations 
to the benefits offered.  
 
We looked at the file, the Plans rules and Medicare rules. The Plan contract says that enrollees only have to 
pay their cost-sharing amount when they get services covered by the Plan. The urgent care services provided on 
January 27, 2023, were covered by the Plan. The Plan did not disclose, in clear accurate terms, that their 
worldwide coverage for urgent and emergent care is limited to Medicare allowed, or reasonable and customary 
rates. Therefore, the Plans contract is ambiguous regarding the limitation they are imposing. Therefore, we decided that the Plan has to reimburse you the amount you have proven to of paid for the covered urgent care 
services, minus your applicable copayment of $40 for urgent care/clinic services provided on January 27, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex. 
 
You asked the Plan to pre-approve Vertiflex. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient evidence of efficacy. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 2 very heavy 
duty, patient weight capacity 451 to 600 pounds (K0808). 
 
You asked the Plan to pre-approve a power scooter. You say that this is the only scooter that will suit you due 
to your weight. You also say that if you take a regular power wheelchair outside your home, the power 
wheelchair will not move. The Plan denied your request. The Plan says the requested scooter is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that group 2 POVs (K0806, K0807, K0808) have 
added capabilities that are not needed for use in the home. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a scooter have not been met. Specifically, the requested scooter is not covered by Medicare 
because it has features that are used outside of the home. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV), group 2 very heavy duty, patient weight capacity 451 to 600 
pounds (K0808).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you disagree with the denial. 
The Plan denied your request. The Plan says you have exhausted the maximum benefit of 24 one-way trips per 
year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips (A0120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management provided on April 30, 2023, by 
an OON provider.   
 
You asked the Plan to pay for the chronic care management. You say that you were the only provider available 
to provide these services. The Plan denied your request. The Plan says the services were not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the chronic care management provided on April 
30, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 for date of service May 29, 2023. 
 
You asked the Plan to pay for procedure code 99231. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J96.90 has an Excludes1 note in relation to R06.00. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure code 99231 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99231 for date of service May 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307) provided on December 
19, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary. The Plan 
denied your request. The Plan says there is insufficient information to support these services. 
 
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 G0480 is drug tests, definitive, 1-7 drug class(es), 
including metabolite(s) if performed. The CPT Code Manual definition of code 80307 is drug test(s), 
presumptive, any number of drug classes, any number of devices or procedures. 
 
We find that the requested drug testing is not supported in the medical record. Specifically, the limited records 
provided do not include results for any presumptive drug tests, and the results of the definitive testing include 
drugs from more than 7 drug classes. The definitive drug testing would be more accurately reported with a 
different CPT code. In addition, the physician order provided is incomplete. There is no evidence that 
presumptive testing was requested, and although a custom definitive panel with a file name appears to have 
been requested, there is no documentation providing details of which drugs are requested in the listed panel. 
Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for drug testing services (G0480, 80307) provided on 
December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (power scooter). 
 
You asked the Plan to pre-approve power scooter. You say that you have difficulty walking long distances 
during outings. The Plan denied your request. The Plan says this power scooter is being requested primarily for 
use outside of the home which is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (power scooter).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WiseDx UTI test provided on November 29, 2022. 
 
You asked the Plan to pay for the WiseDx UTI test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the requested testing exceeds the patient's medical needs. 
 
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 pay for the WiseDx UTI test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the case file does not contain clinical documentation supporting that the WiseDx UTI testing was medically reasonable and necessary for the enrollee in this case. 
 
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 WiseDx UTI test have not been met. Therefore, we decided that the Plan 
does not have to pay for the WiseDx UTI test provided on November 29, 2022.