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

 
We decided that the Plan does not have to pay for the outpatient facility services provided on July 19, 2021. 
 You asked the Plan to pay for the outpatient facility services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says OCE billing guidelines 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that when a procedure code 
billed has a Not recognized by Medicare for OPPS indicator, an I/OCE edit of 62 will be returned. This will 
return a disposition of Return To Provider which indicates the entire claim will not be paid.  
 
We looked at the file and Medicare rules. In this case, the billed code J2545 has a Payment Status indicator of 
B which indicates it is Not recognized by Medicare for OPPS. As this claim has been billed with this code, 
the I/OCE edit of 62 has been returned which indicates the entire claim will be Returned to Provider. Based on 
this information, we decided that Medicare rules for coverage of the outpatient facility services have not been 
met. Therefore, we decided that the Plan does not have to pay for the outpatient facility services provided on 
July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the cystourethroscopy (CPT code 52287) 
and the injection (CPT code J0585) provided on July 28, 2021. 
 
You asked the Plan to waive the cost-share for the services. You say that you are appealing the enrollee's cost-
share responsibility for the services the member received. The Plan denied your request. The Plan says the 
claim was processed accordingly with the enrollee's 2021 EOC benefits. 
 
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 provider billed code 52287 in the amount of $928.00. The allowed amount for code 52287 is $355.41. The 
plan applied a $30.00 office visit copayment benefit to code 52287. The copayment was correctly applied. The 
provider billed code J0585 in the amount of $1,600.00. The allowed amount for code J0585 is $606.00. The 
enrollee had not met their deductible yet at the time this claim was processed. There was a $389.36 amount to 
be met to complete the $400.00 deductible. The plan applied a $389.36 deductible to the allowed amount of 
$606.00, which left a balance due amount of $216.64. ($606.00 - $389.36 = $216.64). The plan applied 20% to 
$216.64 for a coinsurance in the amount of $43.33. ($216.64 x 20% = $43.33). The enrollees total cost share 
(copayment, coinsurance and/or deductible) was $462.69 ($30.00 + $389.36 + $43.33 = $462.69) on the claim 
for date of service July 28, 2021. The enrollee is responsible for the total $462.69 cost share. The enrollee met 
their $400.00 with the claim for date of service July 28, 2021. The $400.00 deductible was met as follows: Date 
of service July 1, 2021, $10.64 and date of service July 28, 2021, $389.36 Total: $400.00 ($10.64 + $389.36 = 
$400.00). 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 cost-share for the cystourethroscopy (CPT code 
52287) and the injection (CPT code J0585) provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on September 17, 2021. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on September 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power leg elevation system. 
 
You asked the Plan to pre-approve a power leg elevation system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the medical records do not show that the member has an inability 
to bend their knee 90 degrees, contractures in their knees, or edema on their lower legs. 
 
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 a power leg elevation system. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal extenuating factors that require power elevating 
leg rests over mechanical standard leg rests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power leg elevation system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power leg elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group two heavy-duty power wheelchair (K0825). 
 
You asked the Plan to pre-approve a group two heavy-duty power wheelchair. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 a group two heavy-duty power 
wheelchair. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation does not indicate the member requires a power wheelchair to accomplish mobility- related self-
care tasks in the home. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group two heavy-duty power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group two heavy-duty power wheelchair (K0825).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services (97161) 
provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that the services should be covered. 
The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $40 
copayment for Outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment for the PT services. the PT services falls within the Outpatient 
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 copayment for physical therapy (PT) services (97161) 
provided on November 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on June 18, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services 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 $290 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $290 copayment for the ambulance transportation services. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance transportation services provided on June 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic ultrasound rendered on November 18, 2021. 
 
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 services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 76856 (pelvic ultrasound) and 93976 (vascular study). 
Code 76856 is a column II code with a modifier indicator of 1 when billed with column I code 93976. 
 Code 76856 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided 
that the Plan does not have to pay for the pelvic ultrasound rendered on November 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred drugs. 
 
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 Hyalgan. Our reviewer says that the 
step criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has trialed viscosupplemental treatments such as Orthovisc or Supartz FX. The reviewer also 
found that the documentation does not outline contraindications or reasons these medications were not 
considered. Without the support of the documentation, Hyalgan is not approved, as step criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Specifically, the file does not indicate that the step 
therapy criteria have been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan 
(J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve metatarsal bar wedge, rocker. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve metatarsal bar wedge, rocker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need the scooter for mobility. The Plan 
denied your request. The Plan says you have been able to ambulate in the house to perform her activities of 
daily living. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 a power scooter. Our physician 
reviewer found that in this case, the documentation does not indicate that you require a power scooter to 
accomplish mobility related self-care tasks or that you are unable to use a cane or walker to assist with mobility 
in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 11, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation by physician rendered on 
January 1, 2021. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and was 
billed with place of service code 22 for an outpatient hospital. The PC is not payable if it is not performed in 
the inpatient setting. Therefore, we decided that the Plan does not have to pay for the blood smear 
interpretation by physician rendered on January 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transthoracic echocardiography (TTE) interpretation and 
reporting services (93312) and color flow velocity mapping (93325) provided on March 19, 2021. 
 You asked the Plan to pay for TTE interpretation/reporting and color flow velocity mapping. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because modifier -59 is not supported for code 93312 and add-on code 93325 is not 
covered when the primary procedure code is not covered. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service. Medicare rules say that providers must 
report services correctly. Providers must report services with the appropriate CPT code. 
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not show that this was a separate, distinct procedural service. Based on 
this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not 
been met. In this case, we have confirmed that code 93325 is an add-on code and has not been billed with an 
appropriate primary procedure code because the primary procedure code is non-covered. Based on the claim 
submitted, Medicare billing criteria have not been met.  Therefore, we decided that the Plan does not have to 
pay for transthoracic echocardiography (TTE) interpretation and reporting services (93312) and color flow 
velocity mapping (93325) provided on March 19, 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 
August 24, 2021, to August 25, 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 there is no documentation of multiple chronic conditions (MCC).  
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 266 (ENDOVASCULAR CARDIAC 
VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC). 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 the enrollee underwent valve 
replacement and the procedure was billed with DRG 266. Per the reviewed documentation the echocardiogram 
revealed left ventricular hypertrophy (LVH) with Grade I diastolic dysfunction. The enrollee was treated with 
IV Hydralazine and Metoprolol/Valsartan. There was no documentation provided necessitating DRG 266. The 
appropriate DRG for these services is 267.  
 
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 August 24, 2021, to August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on March 4, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary and should be 
covered. The Plan denied your request. The Plan says the POS code reported does not match where the sample 
was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the definitive drug testing provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a cardiovascular stress test and a nuclear 
medicine study of the heart provided on November 9, 2021. 
 
You asked the Plan to waive the copayments for a cardiovascular stress test and a nuclear medicine study of the 
heart. You say that you want to know if you are being overcharged. 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 $150 
copayment for outpatient diagnostic testing.  
 You have been asked to pay a total of $136.94, which is less than the $150 copayment for outpatient diagnostic 
testing received on November 9, 2021. A cardiovascular stress test and a nuclear medicine study of the heart 
fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have 
been asked to pay a total of $136.94 ($69.18 copayment + $47.76 copayment + $20 copayment = $136.94). 
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 a cardiovascular stress test and a nuclear medicine study of 
the heart provided on November 9, 2021.