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

We decided that the Plan does not have to pay for the nursing facility care provided on January 21, 2020, to 
January 28, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the physician provided medically necessary 
services in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for 
non-emergent services 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 nursing facility care provided on January 21, 
2020, to January 28, 2020, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ambulance ride with admission to a different 
inpatient rehabilitation facility. 
 
You asked the Plan to pre-approve the transport services.. You say that you'd like to transfer to another facility. 
The Plan denied your request. The Plan says that the transfer 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 transport services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show that a short additional time in the current rehab facility should 
suffice followed by transfer to a lower level of care or home. There was no documented advantage to 
transferring him at this time. The enrollee's needs are being met at the current facility. Therefore, transfer to a 
second rehabilitation facility will be considered 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 transport services. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ambulance ride with admission to a different inpatient rehabilitation facility.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the Cologuard testing provided on March 3, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided a rationale for its denial for the requested testing. 
There is no documentation submitted supporting the Plan?s denial. Without a specific rationale and supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
Cologuard testing provided on March 3, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the treatment of a broken forearm 
provided on April 6, 2020 and the cast application services provided on April 28, 2020, at an outpatient 
hospital facility. 
 
You asked the Plan to waive the copayments for the outpatient hospital services. You say that you say that you 
should not be charged for outpatient hospital services. The Plan denied your request. The Plan says you were 
charged these copayments 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 $325 
copayment for surgery or other services provided at an outpatient hospital facility.  
 
You have been asked to pay $595.45 for these services, which is less than the total of the two $325 copayments 
for these two dates of service. These services were provided at an outpatient hospital facility.  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 copayments for the treatment of a broken forearm provided on April 6, 2020 and the 
cast application services provided on April 28, 2020, at an outpatient hospital facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the shaving of an epidermal or dermal 
lesion (11301) provided on March 19, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $154 copayment for the Medicare-covered surgery provided at an outpatient 
hospital. This is the Plan allowed amount, which is less than the applicable copayment for this service. 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 shaving of an epidermal or dermal lesion (11301) 
provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on May 26, 2020. 
 
You asked the Plan to waive the copayment for nail clipping surgery. You say that you have never had to pay a 
copayment for this before. The Plan denied your request. The Plan says the correct copayment has been 
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 $200 
copayment for outpatient surgery.  
 
You have been asked to pay a $49.22 which is less than your copayment amount of $200 for nail clipping 
surgery. Nail clipping surgery falls within the outpatient surgery 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 outpatient surgery provided by a participating provider on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flow cytometry services coded 88189 provided on May 
15, 2020. 
 
You asked the Plan to pay for the flow cytometry 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. 
 
In this case, the CPT Code Manual definition of code 88189 is flow cytometry, interpretation; 16 or more 
markers. 
 
We find that CPT code 88189 is not supported in the medical record. Specifically, this code has a status 
indicator of "B". A status indicator of B means that this code is not payable when submitted on an outpatient 
hospital Part B bill type. Based on this information, we decided that Medicare rules for coverage of the flow 
cytometry services have not been met. Therefore, we decided that the Plan does not have to pay for the flow 
cytometry services coded 88189 provided on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgery services provided on October 2, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare does not allow assistant surgeons for this procedure.  
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for CPT codes 37224 and 35875. 
The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. Based on this 
information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for assistant surgery services provided on October 2, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services rendered on 
October 23, 2019. 
 
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 99285 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 99285 is Level 5 emergency department visit for 
evaluation and management of patient with problem immediately threatening life, including comprehensive 
history and physical examination, and medical decision-making of high complexity. 
 
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 these services. Our reviewer says that 
procedure code 99285 is not supported. Our physician reviewer found billing CPT 99285 requires the 
documentation of a comprehensive history, comprehensive examination and medical decision making of high 
complexity.  Furthermore, the complaint is usually one of great severity, which poses an immediate risk to the 
health of the patient.  In this case, the enrollee was seen in the ED for not getting along with his mother.  The 
enrollee was well behaved in the ED and was not deemed to be a threat to himself or others.  Basic laboratory 
testing was performed, and the enrollee was discharged to follow up with his PCP.  As such, the billing of CPT 
99285 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. 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 emergency department (ED) services rendered on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement services provided at 
an outpatient hospital facility from September 16, 2019, to September 24, 2019. 
 
You asked the Plan to waive the copayments for the wound debridement services. You say that you do not 
believe these services should be categorized as 'surgical' because all they did was redress the arm and examine 
the wound. The Plan denied your request. The Plan says these copayments were 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $295 copayment for surgical services provided at hospital outpatient facilities.  
 
The enrollee has been asked to pay $276.86 per date of service because the allowed amount is less than the 
$295 copayment for the wound debridement services. Medicare considers wound debridement to be a surgical 
service. Therefore, the wound debridement services fall within the surgical services benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayments for wound debridement services provided at an outpatient 
hospital facility from September 16, 2019, to September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the Encore Pedal Rocker wheelchair with 
mag wheels and a tungsten frame and full padding purchased on April 16, 2020. 
 
You asked the Plan to provide reimbursement for the pedal rocker wheelchair and accessories. You say that the 
enrollee needs this item and has paid out of pocket but needs to be reimbursed for the cost. The Plan denied 
your request. The Plan says this item was purchased from a supplier that does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no provider or supplier can receive Medicare payment 
if they are not enrolled in the Medicare program. The rules say that for equipment to be covered, it must be 
appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
In this case, the items at issue were purchased from a supplier that is not enrolled in Medicare. In addition, it 
appears that the equipment is being provided for use in a skilled nursing facility which does not meet the 
definition of the enrollee's home. For these reasons, the coverage rules for this equipment are not met. 
Therefore, we decided that the Plan does not have to provide reimbursement for the Encore Pedal Rocker 
wheelchair with mag wheels and a tungsten frame and full padding purchased on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on June 
30, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you went for a cleaning 
only but were charged $25 for another evaluation. The Plan denied your request. The Plan says your dental 
benefits have been exhausted. 
 
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, you also have a maximum benefit of 
one oral evaluation every 6 months. The Plan paid for a comprehensive oral evaluation provided on June 18, 
2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 6, 
2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
frequent falls, ataxia and left foot drop. Medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. 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. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 4, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the Place of Service (POS) 
code billed on this claim is not supported, these tests were ordered by telemedicine which is a prohibited 
action, and these tests are not covered for the diagnoses listed and were performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, lab tests, were requested solely for screening purposes. Medicare does not 
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
laboratory testing provided on January 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay formagnetic resonance imaging (MRI) of the lumbar spine (72148), an MRI of the pelvis (72195) and lumbar and interlaminar epidural or subarachnoid lumbar injections (62323, J1020, J2001, J2795).You asked the Plan to pay forMRI of the lumbar spine, an MRI of the pelvis and lumbar and interlaminar epidural or subarachnoid lumbar injections. You say that you tried to get a referral from your primary care physician butwere unable to.The Plan denied your request. The Plan says that prior authorization must be obtained for services rendered by an out-of-network provider.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 MRI of the lumbar spine, an MRI of the pelvis and lumbar and interlaminar epidural or subarachnoid lumbar injections. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found youunderwent services while outside treatment area due to an acute change (unforeseen) in yourmedical status. Youcould not get referral through the typical means due to availability issues of those yousought to contact. Yourproblem was acute and debilitating enough to seek emergent unapproved care.  This happened while you were outof the areadue to COVID precautions.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the lumbar spine, an MRI of the pelvis and lumbar and interlaminar epidural or subarachnoid lumbar injections have been met.Therefore, we decided that the Plan has to pay formagnetic resonance imaging (MRI) of the lumbar spine (72148), an MRI of the pelvis (72195) and lumbar and interlaminar epidural or subarachnoid lumbar injections (62323, J1020, J2001, J2795). 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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis coded L1851, the addition to lower 
extremity orthosis coded L2397, and the addition to lower extremity coded L2385 provided on April 14, 2020. 
 
You asked the Plan to pay for the knee orthosis coded L1851, the addition to lower extremity orthosis. 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. 
 
We find that CPT codes L1851, L2397, and L2385 are not supported in the medical record. Specifically, the 
documentation does not support any evidence of an established relationship between the enrollee and the 
ordering physician. Based on this information, we decided that Medicare rules for coverage of the knee orthosis 
coded L1851, the addition to lower extremity orthosis have not been met. Therefore, we decided that the Plan 
does not have to pay for the knee orthosis coded L1851, the addition to lower extremity orthosis coded L2397, 
and the addition to lower extremity coded L2385 provided on April 14, 2020.