Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (CPT 99601 and 99602) provided to 
the enrollee. 
 
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare guidance says status code "I= Not valid for Medicare purposes. 
 
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 99601: 
 
Home infusion/specialty drug administration, per visit (up to 2 hours), 
 
CPT 99602: 
 
Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in 
addition to code for primary procedure). 
 
We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, this code has a 
status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not 
valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 
therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy 
(CPT 99601 and 99602) provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have no 
copayments or deductibles. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $395 
copayment for each day for days 1 to 4 for Medicare-covered hospital care.  
 
You have been asked to pay $1,185, or a $395 copayment for each day of a 3-day inpatient hospital stay. An 
inpatient hospital stay falls within the "Inpatient Hospital Care" 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 an inpatient hospital stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood test (80053) provided, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the blood test. You say that you were approved as an in-network provider. 
The Plan denied your request. The Plan says you do not have a contract with the member's 
specific plan. Thus, prior authorization was not obtained by the facility or the provider; therefore, payment has 
been correctly denied. 
 
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 blood test (80053) provided, by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lower level laser therapy (0552T) provided February 27, 
2020. 
 
You asked the Plan to pay for lower level laser therapy. You say that you feel that the reimbursement should be 
processed. You had injured your toe and was unable to walk well. The doctor recommended the low level laser 
therapy which greatly improved your condition. The Plan denied your request. The Plan says this service is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lower level laser therapy have not been met. Therefore, we decided that the Plan does not have to 
pay for lower level laser therapy (0552T) provided February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interspinous spacer device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the medical services you received. 
 
You asked the Plan to waive the copayment for the medical services. You say that you shouldn't be charged 
this copayment because this service should be bundled into the surgery you had. The Plan 
denied your request. The Plan says that you were charged the specialist office visit copayment correctly. 
 
The records show that you had surgery to fix a finger fracture. The surgery was billed with 
procedure code 26735. According to Medicare rules, surgery coded as 26735 has a 90-day global period. Under 
Medicare rules, that means that for the 90-day period following the surgery, certain services provided by the 
surgeon are included in the payment for the surgery itself. You saw the surgeon two days later, so this visit 
occurred during the global surgery period. During that visit, the surgeon billed for three 
separate things: application of a forearm splint, the actual supplies for the splint, and an x-ray of the hand. The 
Plan charged you a $40 copayment for this follow up specialist visit.   
 
We find that the Plan inappropriately charged this copayment. As noted above, certain items and services 
provided after a surgery are included in the cost of the surgery itself. Medicare rules explicitly state that 
supplies and services related to casts and splints are included in the global surgical package. That is why it is 
not appropriate for the Plan to charge separately for these two items. There should have been no additional 
charge for these services as they are considered part of the global surgical package. 
 
You also had a hand x-ray during this visit. According to Medicare rules, x-rays are not part of the global 
surgical package, and are therefore separately charged. However, your Evidence of Coverage states that you 
have no copayment for x-rays. That is why there should be no cost sharing attributed to you for the items and 
services you received. Therefore, we decided that the Plan has to waive the copayment for 
the medical services you received.  
 
 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99284). 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were misdiagnosed 
by the hospital. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $90 
copayment for each visit for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the "Emergency care" 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 an 
emergency room visit (99284).  
 
Maximus Federal Services read your letter and knows that you may have a quality of care.
cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that this surgery and pacemaker are 
medically necessary. The Plan denied your request. The Plan says the medical records do not show the enrollee 
is registered and participating in an approved Medicare clinical research study. 
 
The Plan must follow Medicare rules. Medicare does not cover investigational devices. Medicare only covers 
leadless pacemakers for enrollee's participating in a clinical study and those costs are directed to Original 
Medicare, not the health Plan. Therefore, we decided that the Plan does not have to pre-approve a leadless 
pacemaker for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9501) provided from December 18, 
2019, to December 24, 2019. 
 
You asked the Plan to pay for home infusion therapy. You say that this is supported by the documentation. The 
Plan denied your request. The Plan says this code is not valid. 
 
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 
indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9501) provided from 
December 18, 2019, to December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee and billed under 
codes 80157, 80177, 80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for testing services provided to the enrollee. You say that this claim should be paid. 
The Plan denied your request. The Plan says while codes G0483 and 80307 were paid, the remaining codes 
could not be paid due to an issue with the specimen samples. Blood specimen collection is by venipuncture; 
however, the lab requisition states a urine specimen was collected; therefore, the unpaid billed service cannot 
be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be fully paid due to an 
issue with the specimen type reported. Medicare billing criteria are not met. Therefore, we decided that the 
Plan does not have to pay for lab services provided to the enrollee on December 17, 2019 and billed under 
codes 80157, 80177, 80201, 80162, 80159, and 80173.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are other services available as part of the mental health benefit. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not 
meet the criteria for treatment in the acute inpatient mental health facility beyond October 30, 2020. You could 
be treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory, or 
visual hallucinations. You were not showing any behaviors or aggression. You were cooperative and compliant 
while not showing any acute threats to safety. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient mental health facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided. 
 
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration 
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating 
room throughout the duration of the procedure. The Plan denied your request. The Plan says payment for this 
service is the responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is 
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, 
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because you only called for a prescription refill and never spoke to the doctor. The Plan denied your request. 
The Plan says the claims were processed correctly and you are being charged the correct amount.  
 
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 each specialist visit.  
 
You have been asked to pay the allowed amount of $28.76, which is less than the $50 copayment for a 
specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's 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 waive the copayment for a specialist visit provided.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that care could have been provided at a lower level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided .  
 
 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee had cardiac complications and a need for IV antibiotics. The admission was both 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided.  
 
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 pre-approve a sleep study. 
 
You asked the Plan to pre-approve the sleep study. You say that the enrollee has elevated morning blood 
pressure and snoring issues. The Plan denied your request. The Plan says there is no documentation in the 
medical record of daytime sleepiness, impaired cognition, mood disorders, or insomnia. 
 
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 sleep study. Our reviewer says that 
a sleep study is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has hypertension, reportedly not adequately controlled, with elevated pressures in the morning. The 
medical record does not provide justification for a sleep study. There is no documentation of excessive daytime 
sleepiness, observed apneas, or other symptoms that could be related to obstructive sleep apnea. Hypertension 
alone is not a justification for a sleep study. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psych services provided. 
 
You asked the Plan to pay for inpatient psych services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psych services. Our reviewer says 
that the documentation does not support that the rendered services are medically reasonable or necessary. Our 
physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on with
Major Depressive Disorder, Recurrent, Severe without Psychotic Features, Cocaine Use 
Disorder, Severe, Dependence, Cannabis Use Disorder, Severe, Dependence, Alcohol Use Disorder, Moderate, 
Dependence and Fetal Alcohol Syndrome. The documentation supports that it was not expected this enrollee 
would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
 
 
rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal 
thoughts, auditory or visual hallucinations or abnormal behaviors. The documentation does not include an 
individualized treatment plan; however, the entire record is not present. Therefore, the enrollee did not meet 
criteria for the services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psych services have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient psych services provided.