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

 
We decided that the Plan does not have to pay for testing services provided on January 5, 2023, billed with 
procedure code 76706. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the diagnosis is not consistent with the 
procedure. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for Abdominal Aortic Aneurysm (AAA) for beneficiaries who meet the required criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. This claim was billed with diagnosis code Z13.6, 
described as encounter for screening for cardiovascular disorders, which does not meet the required criteria for 
the service provided. Therefore, we decided that the Plan does not have to pay for testing services provided on 
January 5, 2023, billed with procedure code 76706.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair K0848 with accessories 
and upgraded electronics coded as K0848, E0955, E0960, E1007, E1012, E1028, E2300, E2361, E2607, 
E2620, E2377, E2313, E2311. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are attaching supporting 
documentation for the power mobility device that is medically necessary for the enrollee. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options available with 
K0861 group 3 power wheelchair. Expandable controller, harness and electronics are not medically needed  
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has decreased strength in their legs and a history of falls. The enrollee 
does not have skin breakdown, high risk for skin breakdown, use catheter, or have spasticity that impacts her 
positioning She does not require alternative means of power drive control.  
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 3 power wheelchair K0848 with accessories and upgraded electronics 
coded as K0848, E0955, E0960, E1007, E1012, E1028, E2300, E2361, E2607, E2620, E2377, E2313, E2311.
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 07, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that the records attached support the 
services provided. 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 $54.77 
copayment for Annual wellness visit. 
 
You have been asked to pay a $54.77 copayment for an office visit. This item/service falls within the Annual 
wellness visit 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 Plan paid $82.15 towards the claim, leaving the enrollees responsibility of $54.77. You are 
responsible for a 40% Out of Network Annual Wellness Visit. ($136.92 - 40% = $54.77) Therefore, we decided 
that the Plan does not have to waive the copayment for an office visit provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95861, 95870) provided on May 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Additionally, you billed 2 units of code 
95870. However, the records only show that 1 unit of code 95870 was provided on the date of service in 
question. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (95861, 95870) provided on 
May 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary.  
 
Our physician reviewer found the documentation doesnt support that you require additional skilled nursing 
services to provide treatment that is medically necessary. You do not require additional skilled nursing services 
to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health 
services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SI joint RFA. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that SI Joint Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
sacroiliac (SI) joint radiofrequency ablation (RFA) (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heating pad (E0217) provided from August 11, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for the heating pad. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Per LCD L33784, code E0217 is not covered. Based on this 
information, we decided that Medicare rules for coverage of the heating pad have not been met. Therefore, we 
decided that the Plan does not have to pay for the heating pad (E0217) provided from August 11, 2022, to 
August 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented, home health, skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the pigmented lesion assay (PLA) (0089U) provided on August 23, 
2022.  
 
You asked the Plan to pay for the PLA. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says that criteria were not met for coverage of this test. 
 
The Plan follows Medicare rules. Medicare rules say that PLA is medically necessary when the criteria in the 
rules section of this letter 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 pay for the PLA. Our reviewer says that this service 
was medically necessary. Our physician reviewer found that the enrollee had a history of melanoma and, 
therefore, represented a higher risk requiring PLA testing. This is consistent with community standard of care. 
Thus, the PLA testing is medically reasonable and necessary. 
 
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 PLA have been met. Therefore, we decided that the Plan has to pay for the 
pigmented lesion assay (PLA) (0089U) provided on August 23, 2022.   
 
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 lab services provided on May 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 20, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services (97110, 97112, 97116) provided on 
December 29, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says that these services should be reported with 
code G0151 because they were performed in the enrollees home. 
 
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 these codes are supported in the medical record. Specifically, there is no indication in the medical 
record that the provider billing these services is a home health agency or that these services were rendered 
under a home health plan of care. Just because services are furnished in the home does not automatically make 
them home health services, and therapy services are payable under the physician fee schedule as outpatient 
services when they are rendered in the patients home and not part of a home health plan of care. Based on this 
information, we decided that Medicare rules for coverage of physical therapy services have been met. 
Therefore, we decided that the Plan has to pay for physical therapy services (97110, 97112, 97116) provided on 
December 29, 2022.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study. 
 
You asked the Plan to pre-approve sleep study. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the enrollee does not meet criteria for this service. 
 
The Plan follows Medicare rules. Medicare rules state that polysomnography with PAP titration may be 
indicated for enrollees with sleep apnea under certain conditions. 
 
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 sleep study. Our reviewer says that the 
enrollee meets criteria for a sleep study. Our physician reviewer found the records indicate a diagnosis of 
obstructive sleep apnea (OSA) with a need for positive airway pressure (PAP) titration due to difficulties with 
the enrollee's PAP device. Medicare rules do not require a home test in the absence of significant comorbidities 
as the Plan stated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sleep study have been met. Therefore, we decided that the Plan has to pre-
approve a sleep study.  
 
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 procedure code 88305 billed for date of service February 23, 
2023. 
 You asked the Plan to pay for procedure code 88305. The Plan denied your request. The Plan says payment for 
code 88305 is bundled into payment for code 17313. 
 
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 88305 
is a column II code to column I code 17313. 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 88305 billed for date of service February 23, 
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 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 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 pre-approve in-network coverage for a three (3) month rental of a 
wearable cardioverter defibrillator (K0606) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve in-network coverage for a 3-month rental of a wearable cardioverter 
defibrillator to be provided by an OON provider. You say that the services are necessary. The Plan denied your 
request. The Plan says there are in-network providers that are able to provide these services. Therefore, 
coverage criteria have not been met. 
 
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 
in-network coverage for a three (3) month rental of a wearable cardioverter defibrillator (K0606) to be provided 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac rehabilitation services provided on July 6, 2022, to 
July 8, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON cardiac rehabilitation services. You say that the medical records 
provided warrant the medical necessity of the services billed.  The Plan denied your request. The Plan says the 
services provided do not meet the exceptions that allow for coverage of OON care. 
 
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 cardiac rehabilitation services provided on July 6, 
2022, to July 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 29, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the services provided should be covered. The Plan 
denied your request. The Plan says the service was 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 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 an office visit provided on November 29, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary. The Plan denied 
your request. The Plan says your records show that it is not reasonable to expect that you will be able to fully 
benefit from the intensity of services of an IRF. Services needed may be provided safely in a lower 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.