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

 
We decided that the Plan does not have to pay for surgical services (procedure codes 19303, 19307, 38525) 
provided to the enrollee on October 22, 2021. 
 
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 it cannot be determined how the enrollee came to the servicing provider, or whether the services 
are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator 
of 1, assistant surgeon services are not covered. Medicare rules also 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 19303: 
 
Mastectomy, simple, complete 
 
CPT 19307: 
 
Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but 
excluding pectoralis major muscle 
 
CPT 38525: 
 
Biopsy or excision of lymph node(s); open, deep axillary node(s) 
 
In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 38525. The 
Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that 
Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. 
 
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 the other codes. Our reviewer says that CPT 19303 and CPT 
19307 were not supported by the medical records. Our reviewer found that the documentation did not include 
an operative report to verify the services performed and modifiers used. The billing cannot be verified. 
 
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 surgical services (procedure codes 19303, 19307, 38525) provided to the enrollee on October 
22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 1, 2020, to April 6, 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 provider has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 854 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE WITH CC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the review has determined that the records did not support that 
A41.9 - sepsis, unspecified organism - was reported by the hospital. The appropriate DRG was DRG 505: 
FOOT PROCEDURES WITHOUT CC/MCC.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 1, 2020, to April 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of the requested test in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the enrollee is 70 
years old, and has a smoking history. Nicotine dependence does not satisfy the requirements for this test. The 
records do not quantify the smoking history as to volume, duration  and current activity of the smoking 
history. Without this information the medical necessity of the requested LDCT is not established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a low dose computed tomography (LDCT) scan for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for in-network cardiac rehabilitation visits 
provided from January 26, 2022, to April 14, 2022. 
 
You asked the Plan to waive the copayments for cardiac rehabilitation. You say that you would not have gone 
to these appointments if you knew how much the copayment was. The Plan denied your request. The Plan says 
the copayment applied was correct. 
 
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 $30 
copayment for in-network cardiac rehabilitation services. (32 visits x $30 = $960) 
 
You have been asked to pay a $960 copayment for cardiac rehabilitation. Cardiac rehabilitation falls within the 
In-Network Cardiac Rehabilitation 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 copayments 
for in-network cardiac rehabilitation visits provided from January 26, 2022, to April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says rules for LTACH care have not been 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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. 
 
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the ribs provided to the enrollee on July 5, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says while there are circumstances where a separate second interpretation may be allowable, which are 
defined by Medicare, there is also a specific way to code this. 
 
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 71100 is "Radiologic examination, ribs, unilateral; 2 
views." 
 
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 the x-ray. Our reviewer says that the services at issue in this 
were not supported by the medical records. Our reviewer found that the medical record does not include a 
formal radiology report, or a request for a second interpretation, and therefore was billed incorrectly. 
 
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 x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for an x-ray of the ribs provided to the enrollee on July 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on December 24, 
2021, and January 8, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that a letter you received specifically 
says that these tests are reimbursable. The Plan denied your request. The Plan says these tests were purchased 
before the Plan implemented coverage for OTC at-home COVID-19 test kits. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kits is an OTC item. While Original Medicare started covering these tests on April 4, 2022, 
Medicare Advantage plans are able to elect to provide a supplemental benefit for this or elect not to do so. The 
documentation shows a letter was sent to you by the Plan, informing you that coverage would apply to eligible 
tests that are purchased on or after February 1, 2022, through the end of the federal public health emergency or 
December 31, 2022, whichever is earlier. Therefore, we decided that the Plan does not have to pay for the at-
home COVID-19 test kits purchased on December 24, 2021, and January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON dialysis services. You say that you have been receiving dialysis at the 
same facility for years and feel safe there. The Plan denied your request. The Plan says the requested facility is 
no longer in-network. The Plan has also indicated that they have directed you to a facility that can meet your 
needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit with an ear examination 
using a microscope provided on March 31, 2022. 
 
You asked the Plan to waive the copayments for an office visit with ear exam. You say that you were with your 
provider for less than 5 mins, and this copayment must me incorrect. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $75 
copayment diagnostic procedures and tests. Your contract with the Plan also clearly says that you must pay a 
$30 copayment for a Level 1 specialist visit. 
 You have been asked to pay a $60.08 copayment for an office visit with ear exam which is less than the 
contracted amount ($30 per office visit + 30.08 for a diagnostic procedure = 60.08). An office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits Supplies benefit category. A diagnostic 
procedure falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for an office visit with an ear examination using a microscope 
provided on March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care she needs in the hospital 
where she is now and there is no need to transfer to the LTACH at this time. 
 
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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be completed at the current facility until more appropriate for a lower level of care. The patient does 
not require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that claim should be reconsidered for 
processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496.  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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 15, 
2020. 
 
You asked the Plan to pay for the services. You say that you were unable to submit the claim due to the 
pandemic. The Plan denied your request. The Plan says the claim was submitted outside of the time frame. 
 
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 the services was not filed until October 8, 2021. 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 drug testing services provided to the enrollee on July 15, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 16, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you feel you were given the wrong 
information for the copayment and should not have to pay it. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
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 in-network emergency services.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the In-Network 
Emergency 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 an emergency room 
visit provided on March 16, 2022.  
 Your complaint about the Plans customer service employee giving you the incorrect copayment information is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional formula (B4153, B4155). 
 
You asked the Plan to pre-approve the nutritional formula. You say that the formula is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that  orally administered enteral nutrition products, 
related supplies and equipment will be denied non-covered. 
 
We looked at the file and Medicare rules. This nutritional formula is for oral usage. Based on this information, 
we decided that Medicare rules for coverage of the nutritional formula have not been met. Therefore, we 
decided that the Plan does not have to pre-approve nutritional formula (B4153, B4155).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on Marcy 24, 2022, to 
March 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that inpatient level of care was medically 
necessary. The Plan denied your request. The Plan says these services do not meet criteria for OON coverage. 
 
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 had network providers 
available who could have provided 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 inpatient hospital stay provided on Marcy 24, 
2022, to March 27, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a circulation scan provided on March 7, 
2022. 
 
You asked the Plan to waive the copayment for a circulation scan. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $125 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay the allowed amount of $80.89 which is less than the $125 copayment for a 
circulation scan. A circulation scan falls within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies 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 circulation scan provided 
on March 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 16, 2022.