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

 
We decided that the Plan does not have to pay for outpatient services (CPT 85025 and HCPCS J0881) provided 
to the enrollee on January 22, 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 plan would accept a submission of a corrected claim to consider these services for payment. 
 
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 85025: 
 
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential 
WBC count 
 
HCPCS J0881: 
 
Injection, darbepoetin alfa, 1 mcg (non-ESRD use)  
 
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 CPT 85025 
has a Status Indicator of X - Statutory Exclusion - These codes represent an item or service that is not in the 
statutory definition of "physician services" for fee schedule payment purposes. No RVUS or payment amounts 
are shown for these codes, and no payment may be made under the physician fee schedule. (Examples are 
ambulance services and clinical diagnostic laboratory services.) This code is not eligible for reimbursement 
consideration. HCPCS code J0881 has a status indicator of K and must be submitted along with a payable 
OPPS procedure. A payable OPPS procedure was not billed in conjunction with J0881, therefore it is not 
eligible for reimbursement. 
 
 
 
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 outpatient services (CPT 85025 and HCPCS J0881) provided to the enrollee on January 22, 
2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power wheelchair with tilt in space and additional features. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says that elevated legs rests are available in the previously approved group 3 standard 
power wheelchair with K0195 as an option. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patient?s condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is medically reasonable and necessary. Our physician reviewer found you do not 
possess the upper extremity strength and function to self-propel any manual wheelchair or use a walker or cane 
due to shoulder pain. You are capable of safely operating the wheelchair, and you have been for five years. 
And as per the recommendation by the PT from DME, a replacement group-3 powered wheelchair with 
occupied transit mounts does appear to be appropriate 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 wheelchair have been met. Therefore, we decided that the Plan has to pre-
approve a power wheelchair with tilt in space and additional features.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral exam (D0150) unspecified adjunctive 
procedure (D9915) provided March 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that the office had called the plan to make sure the 
services were covered. You do not feel that you should have to pay for these services. The Plan denied your 
request. The Plan says enrollees must receive their dental services from an in-network provider. 
 
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. The health plan contract on 
page 49 says that you must receive your care from a network provider. 
 
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 
comprehensive oral exam (D0150) unspecified adjunctive procedure (D9915) provided March 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 19, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 did not pre-approve the 
service 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 physician's services provided on November 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the removal of permanent pacemaker 
provided on April 14, 2020. 
 
You asked the Plan to waive the coinsurance for the removal of permanent pacemaker. You say that you cannot 
afford the charges. 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 25% 
coinsurance for surgery services provided in an outpatient hospital facility.  
 
You have been asked to pay $3,700.06, which is less than the 25% coinsurance for the removal of permanent 
pacemaker. The removal of permanent pacemaker falls within the outpatient surgery, including 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 coinsurance for the removal of permanent pacemaker provided on April 14, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 19, 2020 
through February 21, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
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 review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department (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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 19, 2020 through February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited breast ultrasound rendered on March 3, 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 the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 limited breast ultrasound rendered on March 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided by a participating 
provider on March 2, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that this was supposed to be covered at 
full cost. 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 $200 
copayment for outpatient surgery.  
 
You have been asked to pay $200 copayment for a colonoscopy. Evidence was provided to show that polyps 
were removed during the colonoscopy. The rules say that, if during the course of the screening colonoscopy, a 
lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic 
procedure classified as a colonoscopy with biopsy or removal should be billed. A colonoscopy 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 a colonoscopy 
provided by a participating provider on March 2, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating hospital on April 29, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the hospital should have 
seen your break in your foot. You say that you do not feel like you should have to pay this. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since emergency room services 
were provided, the correct copayment has been applied. 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 
provided by a participating hospital on April 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from March 24, 2020 to April 10, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not be 
responsible for this copayment. The Plan denied your request. The Plan says that the copayment applies for 
each time you are admitted. 
 
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 per day for days 1-5 of Inpatient hospital care.  
 
You have been asked to pay a $1,000 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the days 1-5 of 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 the inpatient hospital services provided from March 24, 2020 to April 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure has not been shown to be safe and effective, and is considered 
investigational and experimental. 
 
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 device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. 
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. The device should still be considered 
experimental or investigational. 
 
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 the CardioMEMS device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on September 19, 
2019. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider 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 service 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 out of network physician services provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for a Medicare Part B drug. We decided that the Plan 
does not have to waive the copayment for a specialist visit.  
 
You asked the Plan to waive the copayment for a specialist visit and a Medicare Part B drug. You say that you 
did not have an office visit that day and disagree with the charges. The Plan says that the claims were processed 
correctly and you are being charged the correct amount. 
 
We decided that the Plan has to waive the copayment for a Medicare Part B drug.  
 
The Plan contract says that there is a $0 copayment for Medicare Part B drugs Therefore, we decided that the 
Plan has to waive the copayment for a Medicare Part B drug.  
 
We also decided that the Plan does not have to waive the copayment for a specialist visit. 
 
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 a specialist visit. The medical records show that you had a specialist visit on March 16, 2020. 
Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Plasma-Based Comprehensive Genomic 
Profiling testing provided on January 10, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the testing as billed.. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Plasma-Based 
Comprehensive Genomic Profiling testing provided on January 10, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services provided by a participating facility on May 17, 2020.
You asked the Plan to waive the copayment for observation services. You say that you shouldn't have to pay for this because you were treated poorly. 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 $250 copayment for outpatient hospital observation/hospital observation services. You have been asked to pay a $250 copayment for observation services. The correct copayment has been applied to the services that were provided. Observation services fall within the outpatient hospital observation/hospital observation 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 observation services provided by a participating facility on May 17, 2020.
Your quality of care concerns have been handled separately by the health plan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on March 4, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this 
service is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of in the 
OPPS Addendum B and are listed together in Addendum E of each year?s OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
 on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on February 24, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service 
is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be ?inpatient-only? services. These services have an OPPS status indicator of ?C? in the 
OPPS Addendum B and are listed together in Addendum E of each year?s OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
?C? on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
?inpatient only?, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on February 24, 2020.