Persius/hicric huggingface dataset:
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 for the enrollee. 
The Plan denied your request. The Plan says the records do not support the enrollee requires an intensive team 
to manage 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment (DME) 
provided on May 15, 2023. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment (DME). This item/service falls 
within the Durable medical equipment (DME) 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 
coinsurance for Durable medical equipment (DME) provided on May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
March 22, 2023, to April 11, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on March 22, 2023, to April 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on April 7, 
2023. 
 
You asked the Plan to pay for the hospital care. You say that the service was billed correctly and should be 
paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate POS (22). POS 22 
is for an outpatient hospital or facility. The evaluation and management code (99232) should be billed with a 
POS which indicates inpatient care. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that for services provided to a patient who is registered inpatient or outpatient of a hospital, the 
correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS 
code or that of the appropriate outpatient hospital POS code. 
 
We looked at the file and Medicare rules. We find that the claim was submitted with POS code 22 (on campus 
 outpatient hospital). However, the medical records provided show that the enrollee was registered inpatient 
status on the date in question. According to Medicare rules, this means that this claim should be submitted with 
the appropriate inpatient POS code. Based on this information, we decided that Medicare rules for coverage of 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99232) provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IV sedation for pain relief injections. 
 
You asked the Plan to pre-approve IV sedation for pain relief injections. You say that IV sedation is medically 
necessary. The Plan denied your request. The Plan says the enrollee's doctor has not told us why the enrollee 
needs to be asleep for this procedure and has not told us that the enrollee has first trialed oral medicine that 
reduces anxiety. 
 
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 IV sedation for pain relief injections. 
Our reviewer says that the requested IV sedation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, the provider did not provide specifics surrounding why the 
enrollee requires sedation due to her own medical conditions. Nor did the physician provide information regarding attempts of the use of oral anxiolytics. In addition, there were no anesthesiology records submitted 
documenting intra-operative monitoring of this patient (including blood pressure, heart rate, respiratory rate, 
electrocardiogram, oxygen saturation) or medications administered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IV sedation for pain relief injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve IV sedation for pain relief injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 10, 2023. 
 
You asked the Plan to pay for ambulance services. You say that the Plan should be responsible for the 
remaining cost. The Plan denied your request. The Plan says the allowed amount for this service has been paid. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. If the primary payer does not pay in full for the services, 
Medicare secondary benefits may be paid. 
 
The record shows that your primary insurance payment exceeds the Medicare allowed amount for the services 
at issue, meaning the primary payer paid in full for the services and Medicare secondary benefits may not be 
paid. Based on this information, we decided that Medicare rules for coverage of ambulance services have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided on June 
10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on June 
12, 2023, to July 13, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that the services were 
medically necessary. 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 a home or residence visit 
for the evaluation provided on June 12, 2023, to July 13, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the ambulance services received on August 31, 2023 
minus any cost share requirement. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and hit your head. You also say 
that you could not sit up. The Plan denied your request. The Plan says that the services were billed incorrectly. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules. The rules also say that the GY modifier must be 
used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-
covered or is not a Medicare benefit. 
 
We looked at the file and Medicare rules. Review of the file shows that the provider has billed this claim with 
the modifier GY. While this modifier makes these services not covered, the documentation does not show that 
you were advised these services were not covered. In addition, the documentation shows that you met 
conditions for the prudent layperson criteria due to the fact that you could not sit up and were stuck laying 
down and believed that without immediate medical attention there would be serious jeopardy to your health. 
Based on this information, we decided that Medicare rules for coverage of the ambulance services have been 
met. Therefore, we decided that the Plan has to hold you harmless for the ambulance services received on 
August 31, 2023, minus any cost share requirement.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
July 26, 2023, and billed with codes 87481, 87798, 87652, 87500, and 87640. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the unbundling of lab codes for PCR panel testing is not appropriate.  
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on July 26, 2023, and 
billed with codes 87481, 87798, 87652, 87500, and 87640.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgeries provided on August 31, 
2023, to September 21, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgeries. 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 $420 
copayment for outpatient surgery/surgical procedure performed as anoutpatient at a hospital. 
 
You have been asked to pay a $420 copayment for outpatient surgeries. This item/service falls within the 
outpatient surgery/surgical procedure performed as anoutpatient at a hospital 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 for one surgery, you only owe $330.54. The total amount you owe is $750.54 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgeries provided on 
August 31, 2023, to September 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 for date of service March 1, 2023. 
 
You asked the Plan to pay for procedure code 99308. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 99308 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using total time on the date of the encounter for code 
selection, 15 minutes must be met or exceeded. 
 
We find that CPT code 99308 is not payable as billed. Specifically, this code was billed with diagnosis codes 
L89.103 (Pressure ulcer of unspecified part of back, stage 3) and L89.123 (Pressure ulcer of left upper back, 
stage 3). There is a more appropriate bilateral code to be billed for this diagnosis. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99308 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99308 for date of service March 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for 
you. The Plan denied your request. The Plan says your condition does not meet all the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not available at the acute care 
hospital. There are no services available at the LTACH that you require that are not available at the health care 
setting being offered by the health plan. Given there are offered alternatives, LTACH is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Fillauer AllPro foot (L5981). 
 
You asked the Plan to pre-approve a Fillauer AllPro foot. You say that the items are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. The 
enrollee's current foot is still under warranty. 
 
The Plan follows Medicare rules. Medicare rules say that Lower Limb Prostheses are covered when specific 
criteria 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 a Fillauer AllPro foot. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee's current foot 
ankle system is functioning well. No medical necessity to replace a system less than 3 years old and allowing 
the enrollee to function well at K3 level. 
 
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 Fillauer AllPro foot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Fillauer AllPro foot (L5981).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90714, 90471, and 93005 billed for date of 
service January 19, 2023. 
 
You asked the Plan to pay for the billed services. You say that the billed codes are payable. The Plan denied 
your request. The Plan says the codes are 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 CPT code. 
 
We find that code 90714 has a status indicator of N. Payment is packaged into payment for a separately paid 
service. We find that codes 90471 and 93005 have a status indicator of Q1. Payment for these services is 
packaged into the payment for a service with a status indicator of V, such as billed code 99284. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 90714, 90471, and 93005 billed for date of service January 19, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 11, 2023. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on July 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging service 
provided on August 28, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging service. You say that you 
should not have to pay for this service. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $350 copayment for the magnetic resonance imaging service. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 $249.23. Therefore, we decided that the Plan does not have to 
waive the copayment for the magnetic resonance imaging service provided on August 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 10, 2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a screening autoinflammatory and autoimmunity syndrome panel, was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on July 10, 2023.