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

 
We decided that the Plan does not have to pay for the panel testing billed for date of service August 22, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
billed for the panel. 
 
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.  
 
 The file shows that a urinary tract infection panel was billed with codes 87500, 87641, 87798, 87491, 87496, 
87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, 87653, and G0452. 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 panel testing billed for date of service August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism (E0630) provided on July 18, 2023. 
 
You asked the Plan to pay for the seat lift mechanism. You say that this item was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims lines billed with codes without a KX, GA 
or GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The claim line was not billed with a required modifier. Based on this 
information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met. 
Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0630) provided on July 
18, 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 the enrollee requires specialized rehabilitation 
nursing care for lab/vital monitoring, pain control, bowel/bladder management, fall risk prevention, and family 
education. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physical medicine and 
rehabilitation physicians supervision 3 times a week in an IRF. At the current functional level, the enrollee, 
does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The enrollee needs physical therapy and occupational therapy. The 
document does not support necessity for admission to an IRF. The complexity of the enrollees medical, 
rehabilitation, and nursing needs (combined complexity) does not require acute hospital inpatient rehab stay 
with an interdisciplinary approach to rehabilitative care. There is no medical complexity to require an IRF 
admission. The enrollees rehabilitation needs can be safely provided in a low intensity alternate setting such as 
in a skilled nursing facility.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0483 and 80307 for date of service May 18, 2023. 
 
You asked the Plan to pay for codes G0483 and 80307. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the medical 
records provided do not include laboratory results for the codes billed. Based on this information, we decided 
that Medicare rules for coverage of codes G0483 and 80307 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes G0483 and 80307 for date of service May 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 for date of service April 18, 2023. 
 
You asked the Plan to pay for procedure code 99291. 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 N19 has an Excludes1 note in relation to N18.6. 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 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 for date of service April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve block injection described by code 64450 performed 
on date of service March 22, 2023. 
 You asked the Plan to pay for 64450. You say that 64450 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 64450 is denied because a review of the records 
indicates this service was performed intraoperatively. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block injection for 
postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode 
of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the 
adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection. 
 
We looked at the file and Medicare rules. In this case, the records clearly indicate that 64450 was performed at 
the surgeon's request and as primary anesthetic rather than for postoperative pain management. There is no 
evidence in the record that 64450 was administered for postoperative pain management. In fact, records support 
that a separate nerve block injection service was requested by the surgeon and performed for postoperative pain 
management. Based on this information, we decided that Medicare rules for coverage of 64450 have not been 
met. Therefore, we decided that the Plan does not have to pay for the nerve block injection described by code 
64450 performed on date of service March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E1002, E1012, E1028, E2311, E2361, and 
E2622). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that you would like the provided documentation to be reconsidered for the K0856 base and all 
recommended components needed to meet the enrollee's current medical, mobility, and functional needs. The 
Plan denied your request. The Plan says the enrollee does not have medical need for single power option 
included with K0856 Group 3 power wheelchair. The Plan also says the electronic connection is not reasonable 
and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with single 
power option (such as code K0856) 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 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has quadriparesis from a spinal cord injury, and has been functionally 
impaired since 2018. The enrollee is able to stand, can transfer independently and has intact skin. Our reviewer 
also found that the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
 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 standard 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 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0955, E1002, 
E1012, E1028, E2311, E2361, and E2622).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialty care visit and debridement, 
subcutaneous tissue provided on July 24, 2023, and August 7, 2023. 
 
You asked the Plan to reduce the copayment for the specialty care visit and debridement, subcutaneous tissue. 
You say that you believe that the place of service was the same for each date of service and you do not agree 
with the copayment amounts. 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 each Medicare-covered specialty care visit (when services are provided by a specialist or other 
healthcare professional) and $275 copay for Medicare-covered surgical services performed in an outpatient 
department of a hospital.  
 
You have been asked to pay a total of $585 for the specialty visit and debridement, subcutaneous tissue. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
July 24, 2023 Specialty care visit $338.37 $35 $35 
July 31, 2023 Debridement $338.37 $275 $275 
August 7, 2023 Debridement $338.37 $275 $275 
TOTAL:    $585 
 
These services fall within the physician/practitioner services, including doctors office visits and outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 reduce the copayment for the specialty care visit and debridement, 
subcutaneous tissue provided on July 24, 2023, and August 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 22, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tangential biopsy of skin provided on April 03, 2023. 
 
You asked the Plan to pay for tangential biopsy of skin. You say that this service is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for tangential biopsy of skin 
provided on April 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hemlibra injection (J7170) provided on July 27, 2023. 
 
You asked the Plan to pay for the Hemlibra injection (J7170). You say that the enrollee has an active bleed and 
needs the self-infuse drug Hemlibra to stop the bleeding. The Plan denied your request. The Plan says the 
records do not indicate that the enrollee has received the requested injection on July 27,2023.  
 
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 J7170 is Injection, emicizumab-kxwh, 0.5 mg. 
 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 Hemlibra injection (J7170). Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our reviewer found that the enrollee 
has acquired coagulation factor deficiency and a nosebleed who was reported to have received the self-infused 
drugs Hemlibra to stop the bleeding. However, although the records show the medication was prescribed and 
sent to the enrollee on July 27, 2023, there is no indication that the enrollee had used the requested injection on 
July 27, 2023, to support the code J7170. 
 
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 Hemlibra injection (J7170) have not been met. Therefore, we decided that 
the Plan does not have to pay for the Hemlibra injection (J7170) provided on July 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
July 13, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $50 
copayment for outpatient diagnostic tests/outpatient facilitiesfor diagnostic radiology services. 
 
You have been asked to pay a $50 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/outpatient facilitiesfor diagnostic radiology 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. However, since the allowed amount is 
less than the standard copayment, you only owe $46.71. Therefore, we decided that the Plan does not have to 
waive the copayment for an outpatient diagnostic test provided on July 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the device evaluation provided on July 14, 
2023. 
 
You asked the Plan to reduce the copayment for the device evaluation. You say that you should only have a 
$20 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 $40 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the device evaluation. This item/service falls within the in-
network physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for the device evaluation provided on July 14, 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 services at a skilled nursing facility (SNF) will not 
give the enrollee the best opportunity to regain their baseline quality of life. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, but skilled therapies at home with home healthcare or 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 of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve dialysis. You say that this is necessary. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan and the enrollee can be treated within the Plan network. 
 
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 
dialysis to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823), battery 
(E2365), and battery charger (E2368). 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair, battery, and battery charger. The Plan 
denied your request. The Plan says the denial is upheld because there is no documentation of any completed 
mobility assessment. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 2 standard power wheelchair, 
battery, and battery charger. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the documentation available for review does not support that you require a power mobility 
device to accomplish mobility related self-care tasks in the home. Our reviewer also found that there is no 
indication that you are unable to use an alternative assistive device. 
 
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 2 standard power wheelchair, battery, and battery charger have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power 
wheelchair (K0823), battery (E2365), and battery charger (E2368).