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

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
September 27, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on  
September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nutritional supplements rendered on August 3, 2022. 
 
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 a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pay for are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pay for the nutritional supplements rendered on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service July 3, 2022. 
 
You asked the Plan to pay for procedure code 99239. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99239 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99239 billed for date of service July 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service January 30, 
2022. 
 
You asked the Plan to pay for procedure code 99233. 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem.  Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, this code was billed with 
primary diagnosis J12.82 (Pneumonia due to coronavirus disease 2019). Diagnosis code J12.82 is listed with a 
code first entry which means diagnosis code U07.1 (COVID-19) should be listed as the primary diagnosis. 
Diagnosis code U07.1 is listed as the secondary diagnosis. The claim is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99233 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99233 billed for date of service 
January 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the remote physiological monitoring (RPM) services provided on June 
28, 2022, billed with one unit of code 99457 and 3 units of 99458. 
 
You asked the Plan to pay for the RPM services as billed. You say that this was billed correctly for the total 
time spent in the month providing this service. The Plan denied your request. The Plan says that the Medically 
Unlikely Edit (MUE) value for code 99457 is 1 and was exceeded. As such, the claim was correctly denied. 
 
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. The Plan has incorrectly indicated that the MUE has been exceeded for code 
99457. The MUE of this code is 1 unit. Only 1 unit was billed. The code 99458 was only denied stating that the 
payment was not made for the primary. Since the primary code was denied inappropriately, there is no rationale 
for denial of 99458. Three units are also the MUE for this code, which was not exceeded. We find that the 
denial of payment for these services is not supported. Therefore, we decided that the Plan has to pay for the 
remote physiological monitoring (RPM) services provided on June 28, 2022, billed with one unit of code 
99457 and 3 units of 99458.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you still require assistance to get out of bed and use 
the restroom. You say you are a fall risk, and there is no one at home to care for you. The Plan denied your 
request. The Plan says your condition does not meet the requirements for an inpatient stay in a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The clinical 
documentation shows that inpatient skilled therapy goals have been met and evaluating therapists recommend 
ongoing skilled therapy on an intermittent basis in the home setting. You do not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code(s) 85025, 80053, and 84443 billed for date of 
service August 24, 2022. 
 
You asked the Plan to pay for procedure code(s) 85025, 80053, and 84443. You say that you disagree with the 
denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing facility 
payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 85025, 80053, and 84443 have a Professional/Technical indicator of 1. This means that 
CPT codes 85025, 80053, and 84443 have both a professional and technical component. In this case, CPT 
codes 85025, 80053, and 84443 have not been billed with an appropriate modifier to indicate the professional 
component. Based on this information, we decided that Medicare rules for coverage of procedure codes 85025, 
80053, and 84443 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code(s) 85025, 80053, and 84443 billed for date of service August 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
November 12, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
claim needs to be submitted to the member's primary insurance first and then the claim will need to be 
submitted to the Plan in order for the Plan to pay their portion of the claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
outreach to the billing provider to advise them that claim needs to be submitted to the enrollees primary 
insurance first and then the claim will need to be submitted to the Plan in order for the Plan to pay their portion 
of the claim. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit provided on November 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on October 24, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the services provided were 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 pay for the radiology services provided. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the claim this was billed with diagnosis code Z13.6 (Encounter for 
screening for cardiovascular disorders) and F17.210 (Nicotine dependence, cigarettes, uncomplicated) which 
does not indicate the criteria of a family history of abdominal aortic aneurysm, a man aged 65 to 75 who has 
smoked at least 100 cigarettes in his lifetime, or other risk factors recommended by the United States 
Preventive Services Task Force. Also, documentation received does not indicate that the patient received the 
screening study for one of the risk categories of a family history of abdominal aortic aneurysm, a man aged 65 
to 75 who has smoked at least 100 cigarettes in his lifetime, or other risk factors recommended by the United 
States Preventive Services Task Force. The review has determined that the items/services at issue in this case 
were not medically reasonable or necessary. 
 
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided on October 24, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from July 21, 2022, to September 22, 2022.

You asked the Plan to waive the copayment for SNF care. You say that you were told the insurance was going to be paying this and there would be no charge to you. 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 for SNF care, enrollees must pay $0 copayment per day, per admission, for days 1 to 20, and $100 copayment per day, per admission, for days 21 to 100.

You have been asked to pay $3,900 for SNF care. You used 59 skilled nursing facility care days. There were 37 days of skilled nursing facility care from July 21, 2022, to August 27, 2022. There were 22 days of skilled nursing facility care from August 31, 2022, to September 22, 2022 (37+22=59). Your contract with the Plan says no cost sharing is assessed for the first 20 days of SNF care, and that for days 21 to 100, a $100 copayment per day is assessed. You are responsible for the copayments assessed for 39 days of SNF care (59-20=39). The total you owe is $3,900 ($100/day x 39 days = $3,900). This item/service falls within the skilled nursing facility (SNF) care 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 SNF care provided from July 21, 2022, to September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651), and segmental pneumatic appliance for use with pneumatic 
compressor, each leg (E0667 x 2) to be provided by an out-of-network (OON) supplier. 
 
You asked the Plan to pre-approve lymphedema pump. You say that the enrollee has lymphedema in both legs. 
You say that there is no other supplier that can provide the enrollee the dual wave mode found in the Medi 
Genius. You also say that the wave will provide therapy in two different areas of the limbs simultaneously. The 
Plan denied your request. The Plan says the items can be provided in network. 
 
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 confirmed there are 
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 a pneumatic compressor, segmental home model without calibrated gradient pressure 
(E0651), and segmental pneumatic appliance for use with pneumatic compressor, each leg (E0667 x 2) to be 
provided by an out-of-network (OON) supplier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visits with an ophthalmologist 
provided on April 19, 2022, and April 25, 2022. 
 
You asked the Plan to waive the copayment for the office visits. You say that when you went to the 
ophthalmologist on April 19, 2022, the provider stated the hospital had a better machine and scheduled you to 
go back on April 25, 2022. You also say that you never received the laser eye surgery. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copay for Vision care.  
 
 You have been asked to pay a $20 copay for the office visits. These services fall within the Vision care 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 the office visits with an ophthalmologist 
provided on April 19, 2022, and April 25, 2022.  
 
Your complaint about the Plan being billed for services that were never provided 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 pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided October 12, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 14, 2022, billed with 
codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328, 81335, 81401, 81401, 81306 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 14, 2022, billed with codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328, 81335, 81401, 
81401, 81306 and 81355.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care attendant services. 
 
You asked the Plan to pre-approve personal care attendant services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover custodial care or personal care 
attendant services. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care attendant services have not been met. Specifically, we find that the services at issue 
in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care attendant services.