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

 
We decided that the Plan does not have to pay for a surgical shoulder arthroscopy (29822) provided on May 18, 
2021. 
 
You asked the Plan to pay for a surgical shoulder arthroscopy. You say that the services at issue are separate 
and distinct. The Plan denied your request. The Plan says rules for payment have not been met because the 
services at issue are included in another billed code. 
 
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.   
 
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 a surgical shoulder arthroscopy Our 
reviewer says that the services at issue do not meet criteria for payment.  
 Our physician reviewer found that the operative report describes shoulder arthroscopic subacromial 
decompression, distal clavicle excision, and limited debridement services performed on the left shoulder.  
 
Per Medicare guidelines, if another arthroscopy procedure is billed and paid for the same day, on the same 
shoulder, for the same beneficiary, at the same encounter, the limited debridement coded 29822 is not 
separately payable. In this case, all procedures were performed on the left shoulder during the same session and 
therefore code 29822 would be inclusive to the primary procedure code reported. 
 
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 surgical shoulder arthroscopy have not been met. Therefore, we decided that 
the Plan does not have to pay for a surgical shoulder arthroscopy (29822) provided on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on February 9, 
2022. 
 
You asked the Plan to waive the copayment for the mammogram. You say that you have never paid for this 
procedure before and you thought it was covered. The Plan denied your request. The Plan says the proper 
copayment was applied for the procedure done by an OON provider. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Out-of-network Breast cancer screening per visit.  
 
  You have been asked to pay a $30 copayment for the mammogram. The mammogram falls within the Breast 
cancer screening (mammograms) benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
mammogram provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardioversion procedure (92960) provided on November 9, 
2021. 
 
You asked the Plan to pay for a cardioversion. You say that the service at issue was separate and distinct. The 
Plan denied your request. The Plan says rules for payment have not been met because the service at issue is 
included in another billed code. 
 
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.   
 
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 a cardioversion Our reviewer says that the 
service at issue does not meet criteria for payment. Our physician reviewer found that the operative report 
describes cardioversion performed during the course of a comprehensive electrophysiologic examination. In 
this case, procedure code 92960 would be inclusive to code 93620. 
 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 cardioversion have not been met. Therefore, we decided that the Plan does not 
have to pay for a cardioversion procedure (92960) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a portable liquid oxygen system and an 
oxygen concentrator provided on November 5, 2021. 
 
You asked the Plan to waive the coinsurance for a portable liquid oxygen system and an oxygen concentrator. 
You say that you called the Plan and asked if this was covered, and you were told the Plan covers 80% and you 
cover 20%. You also say you were not told the Plan covers 80% of what Medicare allows, and the 
representative from the Plan gave you misinformation of what the Plan covered. The Plan denied your request. 
The Plan says you were 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 20% 
coinsurance for each Medicare-covered item for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay $30.78 in coinsurance, which is 20% of the allowed amount for a portable liquid 
oxygen system and an oxygen concentrator ($153.90 allowed amount x 20% coinsurance = $30.78). A portable liquid oxygen system and an oxygen concentrator fall within the durable medical equipment (DME) and related 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a portable liquid oxygen 
system and an oxygen concentrator provided on November 5, 2021.  
 
Your complaint about being potentially being misinformed about being reimbursed the allowed amount instead 
of the total amount 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on November 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that the test must be covered consistent with LCD 
criteria. The Plan denied your request. The Plan says the testing does not meet the criteria for coverage. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. The diagnostic test does not have FDA approval or clearance as a companion in vitro 
diagnostic. 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 the lab testing services provided on November 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on December 3, 
2021. 
 You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on 
December 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amitiza for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amitiza for the enrollee.  Benefits for this drug 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 wound care services provided on January 13, 2022, and 
January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that the rendering provider is the only 
specialists that works in the facility, and you would like the claim reprocessed for payment. 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 the wound care services provided on January 13, 
2022, and January 20, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 81406 and 81479 provided on 
December 14, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the laboratory testing provided was cardiovascular genetic screening. The testing 
provided is not one of the cardiovascular screening tests that are covered. This means that the laboratory tests at 
issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 
81406 and 81479 provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
September 14, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you were only 
supposed to pay a copayment for seeing a specialist. The Plan denied your request. The Plan says the 
copayment was applied 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
  You have been asked to pay the allowed amount of $273.55 for the outpatient surgery services rather than the 
standard $295 copayment. The outpatient surgery services fall within the 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 outpatient surgery services provided on 
September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, 
patient weight capacity up to and including 300 pounds (CPT code K0823), adjustable height, detachable 
armrest, complete assembly (CPT code E0973) and 22nf sealed lead acid battery (CPT code E2361). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says there is no documentation the enrollee's mobility limitation cannot be resolved with a 
cane, walker, or manual wheelchair. 
 
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 the DME. Our physician reviewer 
found the documentation notes the enrollee has a mobility deficit, but the documentation does not reveal that 
this mobility deficits impairs MRADLS in the home. The enrollee is independent in dressing, feeding, 
grooming and bathing. The documentation indicates that the enrollee can ambulate 540 feet with a cane and 
can use a walker. The enrollee's strength in the upper extremities, range of motion, and functional abilities does 
not support that this enrollee is unable to use an optimally configured manual wheelchair. While the enrollee 
may be able to safely operate the requested power wheelchair the documentation does not support that this is 
medically necessary per Medicare's LCD: Power Mobility Devices (L33789). 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient 
weight capacity up to and including 300 pounds (CPT code K0823), adjustable height, detachable armrest, 
complete assembly (CPT code E0973) and 22nf sealed lead acid battery (CPT code E2361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the allergen immunotherapy services 
provided on February 17, 2022. 
 
You asked the Plan to waive the coinsurance for the allergen immunotherapy services. You say that you were 
told during the appointment there would be no copayment and it would be covered. The Plan denied your 
request. The Plan says the proper coinsurance was applied for the service rendered. 
 
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% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs. The total amount for the allergen 
immunotherapy was $502.20 with a coinsurance of $100.44 ($502.20 total amount x 20% coinsurance). 
 
  You have been asked to pay a $100.44 coinsurance for the allergen immunotherapy services. The allergen 
immunotherapy services fall within the Medicare Part B prescription drugs 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 coinsurance for the allergen immunotherapy services provided on February 17, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device and 
related supplies provided on March 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a CPAP device and related supplies. You say that the requested items are a 
medical necessity for you. The Plan denied your request. The Plan says rules for payment for out-of-network 
care have not been met. 
 
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 continuous positive airway pressure (CPAP) 
device and related supplies provided on March 21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the postoperative follow-up visit coded 99024 provided on 
December 22, 2021. 
 
You asked the Plan to pay for the postoperative follow-up visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says no payment can be made 
for this service 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 find that CPT code 99024 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99024 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the postoperative follow-up visit have not been met. Therefore, we decided that the Plan does not have to 
pay for the postoperative follow-up visit coded 99024 provided on December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the patient was admitted for coronary artery bypass grafting. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. In this case, the patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81246, 81400, 81413, 81414, 
81442, and 81479 provided on April 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
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. Review of the file shows that the cardiovascular 
genetic screening panel provided was initiated by the laboratory and not by the enrollees treating physician. 
This testing is only covered when ordered by the enrollees treating physician. 
 
In addition, we have confirmed that code 81400 is a column II code to column I code 81413. This claim has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 81246, 81400, 81413, 81414, 81442, and 81479 provided on April 30, 2021.