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

 
We decided that the Plan does not have to pre-approve a left-heart catheterization procedure (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that cardiac catheterization is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cardiac catheterization. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had a negative radionuclide stress test in the past and has a low 
coronary calcium score of 28. The left-ventricular ejection fraction is normal. The provided documentation 
does not reveal the rationale for this invasive imaging study. Guidelines do not support a need for cardiac 
catheterization in this 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left-heart catheterization procedure (93458).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0429, 
A0425) provided on September 27, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation services. You say that you did not 
request these services. The hospital required you to be transported elsewhere; therefore, you feel these services 
should be paid for by the facility. 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 $250 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
 You have been asked to pay a $250 copayment for ambulance transportation services. This item/service falls 
within the Medicare-covered ground ambulance trip 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 ambulance transportation services (A0429, A0425) provided on September 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 22, 2022 to 
February 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have made several attempts 
to timely file your NOA.  You believe the Plan is not enforcing the NOA lateness penalty. The Plan denied 
your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 22, 2022 to 
February 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 20, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve a one-way transportation trip for 76 miles. 
 
You asked the Plan to approve these services. You say that your doctor wants you to go to Dartmouth. The 
Plan denied your request. The Plan says the request exceeds the mileage limit. 
 
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 routine transportation for up to 60 miles per one-way trip. 
 
We looked at your request, the records in the case file, and the rules. You are requesting a one-way trip for a 
total of 76 miles. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to approve a one-way 
transportation trip for 76 miles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to return to baseline and get back to being independent.  The Plan denied your request. The Plan says the 
enrollee does not meet the 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes A4649 and A4556 billed for date of service November 14, 2022.

You asked the Plan to pay for procedure codes A4649 and A4556. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes A4649 and A4556 are considered bundled/excluded.

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 codes A4649 and A4556 have a status indicator of P on the Physician Fee Schedule. This means that procedure codes A4649 and A4556 are bundled/excluded. Based on this information, we decided that Medicare rules for coverage of procedure codes A4649 and A4556 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4649 and A4556 billed for date of service November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra motor for a prosthetic knee (L5859). 
 
You asked the Plan to pre-approve the extra motor. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that this item exceeds the enrollees needs. The Plan follows Medicare rules. Medicare rules say that an extra motor is covered when the criteria listed in 
the Medicare rules section are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the extra motor. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that there is no evidence that the enrollee 
has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps 
function that impairs K3 level function with the use of a microprocessor-controlled knee alone. The request is 
to increase power on grass and carpet. 
 
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 extra motor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an extra motor for a prosthetic knee (L5859).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve skilled nursing facility services. The Plan denied your request. The Plan 
says the enrollee's inpatient stay has reached the 100-day benefit limit for this admission. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 10, 2023, through 
Jun 19, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4223 billed for date of service November 
16, 2022 to November 25, 2022.  
 You asked the Plan to pay for procedure code A4223. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code A4223 is 0. The MAI value for this code is 2. You billed 1 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code A4223 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A4223 billed for date of service November 16, 2022 to November 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service January 30, 
2023. 
 
You asked the Plan to pay for procedure code A4557. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4557 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 A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4557 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4557 billed for date of service January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
February 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told to go to a new provider to get a 
cleaning and the x-rays were never sent over. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a complete series of radiographic images (D0210) on February 20, 2023; therefore, 
your benefit for the requested item or service was exhausted on the date of service of February 20, 2023. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service February 27, 
2023.  You asked the Plan to pay for procedure code 64488. You say that these services were reported correctly. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 64488 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. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64488 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64488 billed for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87500, 87641, and 87653 
billed for date of service November 10, 2022. 
 
You asked the Plan to pay for procedure code 87150. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the codes are 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, we have confirmed that code 87150 
is a column II code to column I code 87500, codes 87481, 87653, and 87641 are column II codes to column I 
code 87801. This claim has not been billed with an appropriate modifier to bypass the edit. The -XU modifier 
is not supported as separate and distinct procedural 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 87500 is infectious agent detection by nucleic acid (DNA 
or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT code 87500 is not supported in the medical record. Specifically, there is no documented 
order for this testing. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. 
 
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 codes 87150, 87481, 87500, 87641, and 87653 billed for date of service 
November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says that the IRF care is medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The enrollees care needs are in fact sufficiently complex, and the enrollee would be able to 
participate in and benefit from physical therapy, occupational therapy, and medical management of new cardiac 
medications, especially in the setting of new onset atrial fibrillation, to prevent any avoidable acute hospital 
readmission and ensure the enrollee returns to the right home setting and with the right services.   
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 rendered on December 9, 
2022. 
 
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 these services are not supported for separate payment. 
 
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 codes 87481 and 87653 is a column II code to column I code 87801; 
however, 87653 was billed with a modifier. CPT 87481 was not reported with any modifier and is therefore not 
verified. 
 
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 CPT 87653 with modifier XU. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our reviewer found that the provider 
performed multiples tests with amplified probe technique. In this case, this procedure would be included in the 
primary procedure code when performed. Modifier XU (unusual non-over lapping) cannot be verified, as the 
laboratory report does not include documentation to support modifier reported. 
 
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 procedure codes 87481 and 87653 rendered on December 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 7 hours (9 units) of neuropsychological 
testing (96121 x1, 96133 x4, 96139 x4). 
 
You asked the Plan to pre-approve an additional 7 hours (9 units) of neuropsychological testing. You say that 
this is medically necessary. The Plan denied your request. The Plan says the documentation does not support 
the need for extended testing time 
 
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 an additional 7 hours (9 units) of 
neuropsychological testing. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided medical records in this case 
document a need for "neuropsych evaluation," but the medical records do not clarify the need for 17 hours of 
testing as opposed to 10 hours of testing to meet Medicare criteria for coverage. 
 
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 additional 7 hours (9 units) of neuropsychological testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an additional 7 hours (9 units) of 
neuropsychological testing (96121 x1, 96133 x4, 96139 x4).