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

 
We decided that the Plan has to pay for micro-invasive glaucoma surgery (MIGS)(0191T) provided June 25, 
2020. 
 
You asked the Plan to pay for the surgical procedure. You say that you are asking the plan to reconsider this 
charge and review the documentation submitted attached. The Plan denied your request. The Plan says that the 
records do not support that the Medicare coverage criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the surgical procedure. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found coverage for one iStent, iStent inject is considered medically reasonable and necessary for the 
treatment of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently 
being treated with an ocular hypotensive medication and the procedure is being performed in conjunction with 
cataract surgery. The documentation supports that the enrollee has low-tension glaucoma being treated with 
ocular hypotensive medications, and that the iStent was placed at the time of cataract surgery. 
 
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 surgical procedure have been met. Therefore, we decided that the Plan has 
to pay for micro-invasive glaucoma surgery (MIGS)(0191T) provided June 25, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) 
provided on February 27, 2020. 
 
You asked the Plan to pay for a PET scan. You say that this was billed with correct diagnoses. The Plan denied 
your request. The Plan says this was not billed with a required diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that PET scans must be billed 
with an appropriate diagnosis code.   
 
We looked at the file and Medicare rules. The billed diagnosis codes, C50.919 and R59.0, are not listed as 
appropriate codes.  Based on this information, we decided that Medicare rules for coverage of a PET scan have 
not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography 
(PET) scan (78815) provided on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received at a freestanding 
lab facility on June 26, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you have never had to pay a 
copayment for lab services before. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan says that because the allowed about for these lab services ($16.28) is less than 
your copayment obligation, you are responsible for the full 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 $20 
copayment for lab services at a freestanding laboratory.  
 
You have been asked to pay a $20 copayment for the lab services. The lab services fall within the lab services 
at a freestanding laboratory 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 lab services 
you received at a freestanding lab facility on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 26, 2020, by an OON 
provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the claim should be reprocessed 
and paid at the in-network rate. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
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 medical services provided on June 26, 2020, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (CPT 99203, CPT 99212) provided 
from February 4, 2020, to August 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services (CPT 99203, CPT 99212) provided from 
February 4, 2020, to August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 laboratory services provided on July 9, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for tear duct surgery provided on March 17, 
2020. 
 
You asked the Plan to waive the copayment for tear duct surgery. You say that you disagree with the charges 
because the surgery was not successful. 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 $250 
copayment for outpatient surgery and other medical services provided at ambulatory surgical centers.  
 
You have been asked to pay a $250 copayment for tear duct surgery. Tear duct surgery falls within the 
outpatient surgery and other medical 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 waive the copayment for tear duct surgery provided on 
March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an epidural injection (64483) received on 
July 2, 2020. 
 
You asked the Plan to waive the deductible for an epidural injection. You say that you feel that you have met 
your deductible. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible for Medicare-covered outpatient surgery.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery" benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 
deductible for Medicare-covered outpatient surgery. This cost sharing is a contractual obligation that had not 
been met at the time an epidural injection was received on July 2, 2020. Therefore, we decided that the Plan 
does not have to waive the deductible for an epidural injection (64483) received on July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 1, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the services were necessary. 
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 $350 
copayment for ambulance services.  
 
You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided on June 1, 2020.
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 it is felt that LTACH care is needed. The 
Plan denied your request. The Plan says criteria for LTACH care are not met. 
 
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 the enrollee has a history of end-stage renal disease, myocarditis, CHF, DVT/PE, and 
anemia. The enrollee was admitted to the acute care hospital on 11/19/20 with Covid-19 pneumonia and rapid 
atrial fibrillation. On 12/6/20, the enrollee was comfortable on 1 liter of nasal cannula oxygen. The enrollee 
received antibiotics, convalescent plasma, Remdesivir, and is currently tapering off steroids.  
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short term acute care hospitals. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. Consequently, the requested LTACH services are/are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services coded 99335 provided on August 
5, 2020. 
 
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 99335 is domiciliary or rest home visit for the evaluation 
and management of an established patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are 
spent with the patient and/or family or caregiver. 
 
We find that CPT code 99335 is not supported in the medical record. Specifically, this service was billed with 
place of service 99 (other place of service). The documentation supports that the claim should be billed with a 
different place of service. Based on this information, we decided that Medicare rules for coverage of the rest 
home visit services have not been met. Therefore, we decided that the Plan does not have to pay for the rest 
home visit services coded 99335 provided on August 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance response and treatment 
provided on July 3, 2020. 
 
You asked the Plan to waive the copayment for the ambulance response and treatment. You say that neither 
you nor your husband made the call. You say that you were unaware of the $250 charge for any ambulance 
services. The Plan denied your request. The Plan says the copayment 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 $250 for 
each non-Medicare-covered ambulance stabilization when there is no transport. 
 
You have been asked to pay a $250 copayment for the ambulance response and treatment. The ambulance 
services fall within the "Ambulance 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 ambulance response and treatment provided on July 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on July 30, 
2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you received mixed messages regarding 
whether this service would be covered. The Plan denied your request. The Plan says this service is not covered 
under your supplemental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 (D2391) provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99309 
provided on August 6, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 99309 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has 
developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility floor or unit. 
 
We find that CPT code 99309 is not supported in the medical record. Specifically, this service was billed with 
diagnosis code F01.50 (Vascular dementia without behavioral disturbance) as the primary diagnosis code. This 
diagnosis is a secondary only diagnosis. It is inappropriate to bill this diagnosis code for the primary/first listed 
diagnosis code. Based on this information, we decided that Medicare rules for coverage of the subsequent 
nursing facility care services have not been met. Therefore, we decided that the Plan does not have to pay for 
the subsequent nursing facility care services coded 99309 provided on August 6, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on March 19, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were advised this was an urgent 
care facility. You say that there should be a $10 copayment. The Plan denied your request. The Plan says the 
copayment 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 $75 
copayment for Medicare-covered emergency room visits. 
 
You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the "Emergency Care" 
benefit category. The records show that you were treated in the ER. 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 ER visit provided on March 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services (G0156) provided from July 13, 
2020, to July 19, 2020. 
 
You asked the Plan to pay for home health aide services. You say that this should be covered. The Plan denied 
your request. The Plan says there are not sufficient records to support these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 
We find that CPT code G0156 is not supported in the medical record. Specifically, no medical records for the 
dates of service at issue have been submitted. Without this documentation, these services cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of home health aide services have not 
been met. Therefore, we decided that the Plan does not have to pay for home health aide services (G0156) 
provided from July 13, 2020, to July 19, 2020.
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 LTACH care is necessary. The Plan 
denied your request. The Plan says the enrollee is receiving adequate care in the current facility. 
 
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 the enrollee was admitted to the acute care hospital on 10/23/20 following a cardiac 
arrest at home. The enrollee tested positive for Covid-19. A tracheostomy and a PEG tube have been placed. 
The enrollee has bilateral weakness presumed secondary to critical illness myopathy/neuropathy. Multiple 
pressure wounds are present. On 12/10/20, the enrollee remained on the ventilator. 
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short term acute care hospitals. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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.