Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99239 provided on March 12, 2022. 
 
You asked the Plan to pay for procedure code 99239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan has not provided a claim for review with column one code 
99223 for us to be able to verify that a billing issue has taken place based on Medicare criteria. Therefore, we 
decided that the Plan has to pay for procedure code 99239 provided on March 12, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray, an electrocardiogram (ECG), a 
nuclear stress test, an active ECG, and a computed tomography (CT) scan provided from January 5, 2022, to 
March 14, 2022. 
 
You asked the Plan to waive the copayment for an x-ray, an ECG, a nuclear stress test, an active ECG, and a 
CT scan. You say that you cannot afford these tests. 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 $140 
copayment for other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays. 
a $30 copayment for Over the Counter (OTC) Products 
a $170 copayment (which is less than the full $200 copayment) for outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $1000 deductible - followed by copayments: $30 + $170 + $140 = a total of 
$1340 for an x-ray, an ECG, a nuclear stress test, an active ECG, and a CT scan. This item/service falls within 
the other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays, Over the Counter 
(OTC) Products, and 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 copayment for an x-ray, an 
electrocardiogram (ECG), a nuclear stress test, an active ECG, and a computed tomography (CT) scan provided 
from January 5, 2022, to March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Meningococcal conjugate vaccine (90734) and 
Meningococcal recombinant protein and outer membrane vesicle vaccine (90620) provided on June 23, 2022. 
 
You asked the Plan to pay for the immunizations. You say that the enrollee underwent a splenectomy. You say 
that this puts the enrollee at a higher risk for meningitis and pneumococcal disease. You also say that these 
vaccines were medically necessary. The Plan denied your request. The Plan says the vaccines in this case are 
not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunizations. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunizations. Therefore, we decided that the Plan does not have to pay for the Meningococcal conjugate vaccine (90734) and 
Meningococcal recombinant protein and outer membrane vesicle vaccine (90620) provided on June 23, 2022.  
 
Benefits for the immunizations 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) unit 
provided on June 1, 2022. 
 
You asked the Plan to pay for the TENS unit. You say that the documentation submitted supports the billed 
claim. The Plan denied your request. The Plan says the provider has not submitted proof of delivery for the 
billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain a valid proof of delivery for the supplies provided in this case. The packing slip 
and delivery confirmation support a date of service in March 2022 and not the date of service for this claim. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator 
(TENS) unit provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 9, 
2022. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 24. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on June 6, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 We find that CPT code 83789 is not supported in the medical record. Specifically, this service was billed with 
code G0480 (definitive testing of urine samples for 1-7 drug classes). Code 83789 represents validity testing to 
confirm the results of the drug tests performed. However, Medicare rules say that providers performing validity 
testing on urine specimens utilized for drug testing should not separately bill the validity testing. Based on this 
information, we decided that Medicare rules for coverage of the mass spectrometry and tandem mass 
spectrometry services have not been met. Therefore, we decided that the Plan does not have to pay for the mass 
spectrometry and tandem mass spectrometry services coded 83789 provided on June 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee needs electrical stimulation. The 
Plan denied your request. The Plan says the requested therapy is not covered when received from an out-of-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
24 physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on December 29, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ECG. You say that you are appealing the denied service. The Plan denied 
your request. The Plan says the rendering provider is an OON provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
  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 an electrocardiogram (ECG) provided on 
December 29, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on June 29, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this service was billed with 
code G0480 (drug testing). This procedure code specifically includes mass spectrometry and chromatography. 
Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing 
should not separately bill the validity testing. Based on this information, we decided that Medicare rules for 
coverage of the mass spectrometry and tandem mass spectrometry services have not been met. Therefore, we 
decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry services 
coded 83789 provided on June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92929 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 92929. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 92929 is considered bundled and not separately 
payable. 
 
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 92929 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92929 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92929 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92929 billed for date of service May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids, digitally programmable analog, monaural, 
in the ear (V5246) provided on 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware that you needed to go to 
specific providers for hearing aids. The Plan denied your request. The Plan says the hearing aids are not 
covered because they were purchased through a provider who is not part of the Plan's hearing aid network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you see a provider in the Plans specified hearing aid vendors network and purchase 
the specified branded hearing aids. 
 
We looked at the file and the Plan's rules. In this case you purchased hearing aids from outside of the Plans 
hearing aid vendors network. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids, 
digitally programmable analog, monaural, in the ear (V5246) provided on
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
June 24, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 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 June 23, 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 the subsequent nursing 
facility care (99309) provided on June 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 11, 2022, to 
January 14, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 11, 2022, to 
January 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way transportation. 
 
You asked the Plan to pre-approve the additional one-way transportation. You say that due to your injuries, you 
have many specialist appointments and need the extra rides to be approved. The Plan denied your request. The 
Plan says the request for rides in addition to the 36 one-way rides you are covered for exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you are a dialysis patient and 
need transportation. The Plan denied your request. The Plan says the requested trips exceed your trip limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The Plan provided documentation showing that 24 transports have already been covered. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 24-trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 75-mile trip limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation to an appointment with this provider. The Plan denied your request. The Plan says the requested 
trips exceed the Plan's mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 75 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. In this case the requested transport exceed 
75 miles. Based on this information, we decided that the Plans rules for coverage of routine transportation 
have not been met. Therefore, we decided that the Plan does not have to pre-approve additional miles for 
routine transportation beyond the Plan's 75-mile trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 60-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
make it to scheduled appointments. The Plan denied your request. The Plan says this request exceeds your trip 
limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that at the time of the Plan's review you had used 59 trips and had only 1 remaining trip in your 
transportation benefit. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional trips for routine transportation beyond the Plan's 60-trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation over a 60 mile radius. 
 
You asked the Plan to pre-approve non-emergent transportation over a 60 mile radius. You say that there are no 
arthritis providers in the area that have availability. The Plan denied your request. The Plan says the 2022 EOC 
clearly states each one-way trip must not exceed 60 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 100 one-way trips per calendar year. Each one-way trip must not exceed 60 miles 
based on the most efficient route.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve non-emergent transportation over a 60 mile radius.