Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided from January 5, 2022, to 
January 19, 2022. 
 
You asked the Plan to pay for out of network providers. You say that you feel the Plan should pay these 
services as you did not want to start over with a new plan doctor. The Plan denied your request. The Plan says 
you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan 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 out of network 
services provided from January 5, 2022, to January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomographic angiography of the neck provided 
on February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a computed tomographic angiography of the neck. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says the member's plan excludes 
coverage for this out-of-network service. 
 
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 a computed tomographic angiography of the neck 
provided on February 9, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for injection services provided to the enrollee on October 11, 2021. 
 
You asked the Plan to pay for the services. You say that the codes are payable for the procedures billed. The 
Plan denied your request. The Plan says that payment is not allowed for this drug as it was not billed with 
required corresponding drug administration code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
HCPCS J0178: 
 
Injection, aflibercept, 1 mg 
 
CPT 67028: 
 
Intravitreal injection of a pharmacologic agent (separate procedure) 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that per the medical documentation, the 
enrollee received the injection in the left eye which corresponds to CPT 67028. Per the billing guidelines, this 
code should be coded with the drug code J0178 with NDC 61755-0005-01. The enrollee's medical history 
indicates that the enrollee failed more conservative treatment. The coding is correct. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
injection services provided to the enrollee on October 11, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIPTM MIS Interspinous Fusion 
device. 
 
You asked the Plan to pre-approve the Aurora Spine ZIPTM MIS Interspinous Fusion device. You say that the 
Aurora Spine ZIPTM MIS Interspinous Fusion device is medically necessary. The Plan denied your request. The 
Plan says the Aurora Spine ZIPTM MIS Interspinous Fusion device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Aurora Spine ZIPTM MIS 
Interspinous Fusion device. Our reviewer says that the Aurora Spine ZIPTM MIS Interspinous Fusion device is 
not considered medically reasonable and necessary. Our physician reviewer found the ZIP fusion device 
remains experimental. More research is needed to show safety and efficacy of the device in spinal surgery. 
 
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 Aurora Spine ZIPTM MIS Interspinous Fusion device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Aurora Spine ZIPTM MIS Interspinous 
Fusion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on October 
22, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan 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 out of network services provided to the enrollee on 
October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased on September 18, 2021. 
 
You asked the Plan to pay for the walker. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider is not certified by Medicare. 
 
Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the walker. We found no 
exception that would require the plan to pay for these items/services. Based on this information, we decided 
that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan does not 
have to pay for a walker purchased on September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
December 20, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan 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 out of network services provided to the enrollee on 
December 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Angiography (75710) provided on December 3, 2021. 
 
You asked the Plan to pay for code 75710. You say that the medical records support the billing of code 75710 
provided on December 3, 2021. The Plan denied your request. The Plan says that the medical records do not 
support the billing of code 75710 provided on December 3, 2021. 
 
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 75710 is Angiography, extremity, unilateral, radiological supervision and interpretation. 
 
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 75710. Our reviewer says that the medical records 
support the billing of code 75710 provided on December 3, 2021. Our reviewer found the service that was 
provided meets the criteria for CPT Code 75710.  The procedure itself involved the cannulation of peripheral 
and dialysis access and interpretation. The code was correctly billed. 
 
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 75710 have been met. Therefore, we decided that the Plan has to pay for 
the Angiography (75710) provided on December 3, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 7, 2020, to November 15, 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 payment must be recouped.  
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 840 (LYMPHOMA AND NON-ACUTE 
LEUKEMIA 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 presented with nausea, vomiting, and gastrointestinal bleed (GI) following 
chemotherapy. She was diagnosed with malnourishment. Body mass index (BMI) was 29, with weight loss 
recently, and an albumin of 2.4. Although the presentation supports the documentation of moderate protein-
calorie malnutrition, the enrollee is not below her ideal weight. Therefore, severe protein-calorie malnutrition is 
not supported which would make DRG 841 the most appropriate.  
 
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 November 7, 2020, to November 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 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 you billed with an incorrect place of service on the claim. 
 
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 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 laboratory services provided to the enrollee on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization administration by intramuscular injection of 
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) provided on October 22, 2021. 
 
You asked the Plan to pay for immunization administration by intramuscular injection of severe acute 
respiratory syndrome coronavirus 2 (SARS-CoV-2). The Plan denied your request. The Plan says MA 
organizations should inform their contracted providers about this coverage policy and direct them to submit 
claims for administration of the COVID-19 vaccine to the CMS Medicare Administrative Contractor (MAC) 
for payment. 
 
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 immunization administration by 
intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) provided on 
October 22, 2021 have been met. There are no medical records provided. Therefore, we decided that the Plan 
does not have to pay for immunization administration by intramuscular injection of severe acute respiratory 
syndrome coronavirus 2 (SARS-CoV-2) provided on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided from January 21, 2022, to 
January 24, 2022. 
 
You asked the Plan to pay for the 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. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 27724. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. The services were billed on an 
outpatient claim. Therefore, we decided that the Plan does not have to pay for the surgical services provided 
from January 21, 2022, to January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 26, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains 
not supported. 
 
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 lab 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 laboratory services provided to the enrollee on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided on December 12, 2021. 
 
You asked the Plan to pay for a shower chair. You say that this is for safety and no other choice to purchase. 
Also, it's a covered benefit. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on December 12, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extremity veins provided on  
February 1, 2022. 
 
You asked the Plan to pay for a duplex scan of extremity veins. The Plan denied your request. The Plan says 
prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a duplex scan of extremity veins provided on February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Radiologic examination provided on February 20, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Radiologic examination. You say that that it isn't your responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 Radiologic examination provided on February 20, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the diagnostic services provided on September 22, 2021. 
 
You asked the Plan to pay for the diagnostic services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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 provided no supporting evidence to deny payment for 
these services based on Medicare criteria. Therefore, we decided that the Plan has to pay for the diagnostic 
services provided on September 22, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional ambulance transport services provided to the 
enrollee on October 12, 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 the records submitted do not indicate that two separate services performed or supported. 
 
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 additional ambulance transport 
services provided to the enrollee on October 12, 2021. have been met. The records submitted indicate that there 
was transport from the care facility to dialysis, and then from dialysis back to the care facility. However, both 
of the claims in this case are just for transport from the care facility to the dialysis facility. The provider has not 
sent in sufficient information to show that the claims are not duplicates.. Therefore, we decided that the Plan 
does not have to pay for additional ambulance transport services provided to the enrollee on October 12, 2021.