Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on June 16, 2020. 
 
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 procedure code 99291 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care services spent on the enrollee. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the critical care services rendered on June 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services coded S9501 provided 
from December 12, 2019 to December 18, 2019. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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 CPT code S9501 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9501 provided from December 12, 2019 to 
December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on August 12, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on 
August 12, 2020 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are too weak to do outpatient rehab. The Plan 
denied your request. The Plan says your medical condition is stable, and you are unlikely able to participate in 
an intensive therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for shortness of breath, and was treated for sepsis and a liver 
abscess. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram services (77066, G0279) 
provided on June 15, 2020. 
 
You asked the Plan to waive the copayment for the mammogram services. You say that you do not remember 
having a copayment this high before for mammogram services. The Plan denied your request. The Plan says 
the copayment applied correctly in this case. 
 
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 $20 
copayment for outpatient diagnostic tests and therapeutic services.  
 
You have been asked to pay a $40 copayment for the two mammogram services provided ($20 + $20). The 
services provided fall within the outpatient diagnostic tests and therapeutic 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. Therefore, we decided that 
the Plan does not have to waive the copayment for the mammogram services (77066, G0279) provided on June 
15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgical services rendered 
on May 7, 2020 to May 28, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were applied 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 $345 
copayment for surgery services at an outpatient hospital.  
 
Review of the file shows that you received outpatient surgical services from May 7, 2020 to May 28, 2020. The 
contract with the Plan states that there is a $345 copayment for surgery services at an outpatient hospital. This 
cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the 
Medicare allowed amount for these services was $191.63. Given that the allowed amount was less than the 
$345 copayment, you have been asked to pay $191.63 per date of service for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayments for the outpatient surgical services 
rendered on May 7, 2020 to May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on January 22, 2019. 
 
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says this 
service is not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite provided on January 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary genetic cancer screening testing provided on 
November 12, 2019. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was 
ordered by telemedicine which is a Medicare prohibited action. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
 
 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for hereditary genetic cancer 
screening testing provided on November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left L3-L5 radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no current physical exam, and no description of pain that identifies the pain as 
axial with no radicular component. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a recent physical exam. There has only been one set of diagnostic 
medial branch blocks. The criteria of the LCD has not been met. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left L3-L5 radiofrequency ablation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leuprolide Acetate. 
 
You asked the Plan to pre-approve Leuprolide Acetate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the submitted information is insufficient to support medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Leuprolide Acetate. Our reviewer says 
that the records do not show that Leuprolide Acetate is medically necessary. Our physician reviewer found 
Leuprolide Acetate is indicated for locally advanced or metastatic prostate cancer. Leuprolide Acetate is also 
used for downsizing or downstaging prostate cancer prior to radiation therapy or surgery and for treatment of 
recurrent disease after these treatments have failed. Evidence of these indications was not documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leuprolide Acetate have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Leuprolide Acetate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dermatologist visit you had on July 23, 
2020. 
 
You asked the Plan to waive the copayment for the dermatologist visit. You say that you received a postcard 
from your Plan saying that you wouldn't have to pay copayments for the rest of 2020. The Plan denied your 
request. The Plan says only copayments for primary care visits are being waived. The copayment charged for 
this specialist visit is correct. 
 
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 specialist visits.  
 
You have been asked to pay a $35 copayment for the dermatologist visit. The dermatologist visit falls within 
the specialist 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. Please note that the copayment waiver program mailer you received explicitly states that only PCP 
copayments are being waived through the end of the year.  Specialist copayments are not part of this waiver 
program. Therefore, we decided that the Plan does not have to waive the copayment for the dermatologist visit 
you had on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit (99336) and chronic care management 
(99490) provided on April 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit and chronic care management. You say that medically 
necessary services were provided in good faith. The Plan denied your request. The Plan says prior authorization 
must be obtained for non-emergent services rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the domiciliary visit (99336) and chronic care 
management (99490) provided on April 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0480 provided on March 5, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the submitted 
documentation did not contain a signed physician order for the services provided. In addition, there are no 
authenticated medical records from the ordering provider documenting the treating physician had intended the 
clinical diagnostic testing to be performed. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded G0480 provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on June 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 25, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for injection services (HCPCS J0696) provided to the enrollee on June 4, 
2020. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says that the dosage of the administered drug was not indicated. 
 
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 J0696 is "Injection, ceftriaxone sodium per 250mg." 
 
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 . Our reviewers says that the services at 
issue in this case were supported by the medical records. Our physician reviewer found the code was denied as 
no documentation of the dosage given. There was reference to antibiotics given in the physician's note. Despite 
the lack of documentation of the dosage given, it is noted in the physician record that antibiotics would be 
given.  The billed amount is the lowest dosage of antibiotics that would have been given 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  have been met. Therefore, we decided that the Plan has to pay for injection 
services (HCPCS J0696) provided to the enrollee on June 4, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on June 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the submitted medical records do not indicate the name, credentials, or signature of the servicing 
provider; therefore, the billed services cannot be verified. 
 
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 the denied codes is: 
 
CPT 20610: 
 
Arthrocentesis, aspiration and/or injection 
 
CPT 77002: 
 
Fluoroscopic guidance for needle placement 
 
HCPCS J3301: 
 
Injection, triamcinolone acetonide, not otherwise specified, 10 mg 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation submitted was reviewed, and does not meet the criteria. The procedure report documents "Note 
electronically signed", however, no electronic signature with credentials are documented, therefore, 
confirmation cannot be made of provider performing service. 
 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on June 8, 2020.