Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 82043, 82533, 82570, 
82627, 82670, 82747, 83003, 83525, 83735, 83970, 84144, 84146, 84270, 84305, 84403, 84439, 84443, 84481, 
84550, 84681, 86141, 80053, 80061, 85025, 82172, 83695 and 83698. We decided that the Plan does not have 
to pay for the services described by procedure code(s) 83721.  
 
You asked the Plan to pay for laboratory services provided on October 7, 2022. You say that these services 
were necessary and are supported in the medical record. The Plan says that the payment for code 83721 is 
bundled into the payment for code 80061. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 82043, 82533, 82570, 
82627, 82670, 82747, 83003, 83525, 83735, 83970, 84144, 84146, 84270, 84305, 84403, 84439, 84443, 84481, 
84550, 84681, 86141, 80053, 80061, 85025, 82172, 83695 and 83698.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 82043, 82533, 82570, 82627, 
82670, 82747, 83003, 83525, 83735, 83970, 84144, 84146, 84270, 84305, 84403, 84439, 84443, 84481, 84550, 
84681, 86141, 80053, 80061, 85025, 82172, 83695 and 83698.  We also decided that the Plan does not have to pay for the services described by procedure code(s) 
83721. 
 
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, we have confirmed that code 83721 
is a column II code to column I code 80061. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 83721. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 29823-LT billed for date of service April 5, 2022. 
 
You asked the Plan to pay for code 29823-LT. You say that code 29823-LT is supported and billed correctly. 
The Plan denied your request. The Plan says code 29823-LT is not supported by the medical record. The 
operative report did not include documentation of a surgical shoulder arthroscopy with extensive debridement. 
 
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 29823 is Arthroscopy, shoulder, surgical; debridement, 
extensive, three or more discrete structures (e.g., humeral bone, humeral articular cartilage, glenoid bone, 
glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the 
rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
We asked our coder 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 code 29823-LT. Our reviewer says that code 29823 is not 
supported in the medical record. Our reviewer found the documentation does not support a separately 
identifiable extensive debridement. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 29823-LT have not been met. Therefore, we decided that the Plan does not 
have to pay for code 29823-LT billed for date of service April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282, S9999) provided on November 1, 2022. 
 
You asked the Plan to pay for a wig. You say that a wig for a woman going through chemotherapy should be 
covered. The Plan denied your request. The Plan says this item is not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282, S9999) 
provided on November 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from October 18, 2022, through 
November 16, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee has exhausted their 
100-day SNF benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
   
The file shows that the enrollee has used 128 days of SNF care during the benefit period from May 8, 2022, 
through November 16, 2022, so they have exhausted the 100 day benefit for these services. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for SNF care provided from October 18, 2022, through November 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vygart (efgartigimod alfa-fcab). 
 
You asked the Plan to pre-approve Vygart. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vygart. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of myasthenia gravis. The enrollee is currently maintained on Mestinon, per 
the neurology note dated December 9, 2022. The documentation does not support that the enrollee has tried and 
failed Methotrexate, Azathioprine, Cyclophosphamide, Cyclosporine, Mycophenolate mofetil, or Tacrolimus. 
The documentation does not support that Methotrexate, Azathioprine, Cyclophosphamide, Cyclosporine, 
Mycophenolate mofetil, or Tacrolimus would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vygart have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Vygart (efgartigimod alfa-fcab).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on October 11, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not understand what the denied 
charge was for. The Plan denied your request. The Plan says self-administered drugs are not covered under 
Medicare Part B. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on October 11, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care/homemaker services. 
 
You asked the Plan to pre-approve custodial care/homemaker services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says custodial care/homemaker services are not 
covered by Medicare or offered as a supplemental benefit by the Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care/homemaker services have not been met. Specifically, we find that the services at 
issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-
approve custodial care/homemaker services.
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 the enrollee would benefit from services 
at the LTACH to regain their prior level of function. The Plan denied your request. The Plan says the enrollee 
can continue to receive their ongoing acute care needs at the current acute care setting already approved by the 
health plan. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 
 
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 waive the cost sharing for the thyrotropin alfa injection and the drug 
administration provided by an in-network provider on November 15, 2022. 
 You asked the Plan to waive the cost sharing for the injection and the administration. You say that you do not 
agree with the cost sharing. The Plan denied your request. The Plan says this cost sharing was 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer, 
and a 20% coinsurance for in-network Medicare-covered surgery or other services at an outpatient hospital or 
ambulatory surgical center, including but not limited to hospital or other facility charges and physician or 
surgical charges. 
 
You have been asked to pay a $328.39 coinsurance for the injection because the Plan is only holding you 
responsible for this amount, which is less than the 20% coinsurance. This item/service falls within the 
Medicare Part B prescription drugs benefit category. You have also been asked to pay a $2.77 coinsurance for 
the administration ($13.87 allowed amount x .20 = $2.77). This item/service 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 cost sharing for the thyrotropin alfa injection and the drug 
administration provided by an in-network provider on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you read your annual notice of change and there 
was no mention of limitations except for cleanings. You say that you should be reimbursed for the service you 
received. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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. This benefit includes the 
requested limited oral evaluation (D0140) but is limited to one procedure per plan year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0140 on date of service May 25, 2022. Therefore, this service was exhausted on 
date of service May 25, 2022. Therefore, we decided that the Plan does not have to pay for limited oral 
evaluation (D0140) provided on September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and destruction premalignant lesions provided 
on March 30, 2022.  
You asked the Plan to pay for an office visit and destruction premalignant lesions. You say that the claim needs 
to be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit and destruction premalignant lesions provided 
on March 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray exam provided on January 31, 2022. 
 
You asked the Plan to pay for an x-ray exam. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 24, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an x-ray exam 
provided on January 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on July 
25, 2022. 
 You asked the Plan to pay for the subsequent nursing facility care services. You say that the claim should be 
timely processed for payment. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care services provided on July 
25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 5, 
2022, to December 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid 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 procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service November 5, 2022, to December 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home heath services provided December 27, 2021 to January 
25, 2022. 
 
You asked the Plan to pay for the home heath services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules 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 looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home heath services have been 
met. The provided records did not included the required Outcome and Assessment Information Set (OASIS) 
data. Therefore, we decided that the Plan does not have to pay for home heath services provided December 27, 
2021 to January 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the topical gel and the light procedure 
provided from September 15, 2022, to October 12, 2022. 
 
You asked the Plan to waive the cost share for the topical gel and the light procedure. You say that you never 
had to pay so much for each treatment. The Plan denied your request. The Plan says this cost sharing was 
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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan clearly also says that you must pay a $260 copayment for Medicare-covered surgery provided to you at hospital outpatient facilities. 
 
You have been asked to pay 20% coinsurance for the topical gel. These items/services fall within the Medicare 
Part B prescription drugs benefit category. You have been asked to pay up to the standard copayment of $260 
for the light procedure. These items/services fall within the outpatient surgery and other medical services 
provided at hospital outpatient facilities benefit category. 
 
Date of Service CPT code Allowed amount 20% Coinsurance Copayment 
September 15, 2022 J7345 $230.80 $46.26  
September 15, 2022 96567 $188.95 $0.00 $188.95 
Claim Total   $235.21 
September 29, 2022 J7345 $236.40 $47.28  
September 29, 2022 96567 $188.95 $0.00 $188.95 
Claim Total   $236.23 
October 12, 2022 J7345 $230.80 $46.26  
October 12, 2022 96567 $188.95 $0.00 $188.95 
Claim Total   $235.21 
 
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 cost share for the topical gel and the light procedure provided from 
September 15, 2022, to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided on June 30, 2021. 
 
You asked the Plan to pay for procedure code 99232. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare 
criteria. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for procedure code 99232 was not filed until August 19, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 provided on June 30, 2021.