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

 
We decided that the Plan does not have to pay for physician services (99233) provided on January 22, 2022 to 
January 23, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99233 is not supported in the medical record. Specifically, the claim was submitted 
with an inpatient place of service (21), however records do not show that the enrollee was an inpatient at the 
time the services were rendered. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99233) provided on January 22, 2022 to January 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service September 
17, 2021. 
 
You asked the Plan to pay for procedure code 99072. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99072 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
10, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that I had the same visit in 
2021 and didn't need to pay anything. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $35 
copayment for Physician/Practitioner Services, Including Doctors Office Visits.  
 
You are being charged $22.31 rather than the full copayment amount of $35 for a specialist office visit. A 
specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided 
on May 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 28, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were misinformed and unaware that 
you would be required to pay a $375 copayment. You say that this is a financial burden, and you are unable to 
pay. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $375 
copayment for each Medicare-covered diagnostic radiology service other than CT scans.  
 
You have been asked to pay a $375 copayment for an MRI. An MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and 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 copayment 
for an MRI provided on March 28, 2022.  
 Your complaint about feeling misinformed of the copayment for an MRI 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the not otherwise classified (NOC) drugs, other than 
inhalation drugs, (J7799 x 3) provided on March 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the NOC drugs. You say that the claim should be processed as medical and not 
pharmacy. You also say that these codes have been processed and paid for previous dates of service for the 
enrollee. The Plan denied your request. The Plan says prior authorization was not obtained before the services 
were rendered to the enrollee. 
 
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 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 not otherwise classified (NOC) drugs, other than inhalation 
drugs, (J7799 x 3) provided on March 24, 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 moderate sedation (code 99153) and vascular ultrasound 
(code 76937) provided on March 1, 2022. 
 
You asked the Plan to pay for moderate sedation and vascular ultrasound. The Plan denied your request. The 
Plan says multiple attempts were made to contact the provider for additional information. For Medicare to 
consider coverage and payment for any item or service, the information submitted by the supplier or provider 
must corroborate the documentation in the beneficiarys medical documentation and confirm that Medicare 
coverage criteria have been met. 
 
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 moderate sedation (code 99153) and 
vascular ultrasound (code 76937) provided on March 1, 2022 have been met. Therefore, we decided that the 
Plan does not have to pay for moderate sedation (code 99153) and vascular ultrasound (code 76937) provided 
on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you believe the services should be covered. The 
Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85027 billed for date of service May 29, 
2020. 
 
You asked the Plan to pay for procedure code 85027. You say that this service is supported in the medical 
record and should be paid. The Plan denied your request. The Plan says payment for code 85027 is bundled 
into payment for code 85025. 
 
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, we have confirmed that code 85027 
is a column II code to column I code 85025. 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 procedure code 85027 billed for date of service May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you did not realize you 
needed a referral to continue treatment and further testing. The Plan denied your request. The Plan says the 
claim denied correctly. 
 
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 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 office visit provided on May 9, 2022, by an out-of-network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received 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 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 home health services provided on January 19, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), an electrical 
connection between controller and two more motors (E2311) and a harness upgrade (E2313). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you are home bound. You need the 
requested chair and accessories to help regain some independence. You also say you are bed bound and not 
able to walk. The Plan denied your request. The Plan says the enhanced/upgraded electronics exceed your 
needs. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested items exceed your medical needs and do not meet Medicare medical 
necessity criteria. You do not require a ventilator, or non-proportional input devices (e.g., sip and puff, head 
array, etc.). You do not require a separate display (i.e., for alternate control devices), other electronic devices 
(e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. You have 3 power options of tilt, recline, and power elevating leg rests but you do not need to control 
the power options through a joystick. Your upper extremity strength and function support that you can control 
any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377), an electrical connection between controller and 
two more motors (E2311) and a harness upgrade (E2313).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for colonoscopy on March 01, 2022. 
 
 You asked the Plan to waive the cost sharing for colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $500 
deductible for in-network and out-of-network medical services. You must pay a $3,500 out-of-pocket 
combined maximum. The provider billed in the amount of $6,224.00 and the allowed amount was $534.56. 
You are responsible for a deductible amount of $366.80 and a cost share of $167.76. $366.80 + $167.76 = 
$534.56. Therefore, results in the total cost sharing amount of $534.56. 
 
You have been asked to pay a $534.56 cost share for colonoscopy. Colonoscopy falls within the Outpatient 
surgery and other medical service 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 cost sharing for colonoscopy on March 01, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service September 
10, 2021. 
 
You asked the Plan to pay for procedure code 36556. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 36556 is bundled into payment for code 93503. 
 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, we have confirmed that code 36556 
is a column II code to column I code 93503. 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 procedure code 36556 billed for date of service September 10, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and lab work to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are very sick and a cancer patient. The Plan 
denied your request. The Plan says that the medical care you require can be provided by a 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 a consultation and lab work to be provided by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided September 10, 2021, to 
September 15, 2021 billed with principal diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient services billed with principal diagnosis code A41.9.. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the DRG billed is not 
supported by the documentation. 
 
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 principal diagnosis code A41.9, defined as sepsis, 
unspecified organism. 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 inpatient services 
billed with principal diagnosis code A41.9. Our reviewer says that the documentation does not support the 
DRG billed. Our physician reviewer found though a diagnosis of sepsis was noted during the stay, laboratory 
data reflected the enrollee was without clear signs of systemic response there did not appear to be evidence of 
significant thrombocytopenia or hepatic dysfunction. The enrollee's recent diagnosis and history of urinary tract 
infection and creatinine 0.9-1.4 after treatment in the emergency department. This is a direct organ dysfunction 
and would not be counted toward the SOFA score. There was no mean arterial pressure less than 70 and blood 
cultures revealed no growth. The enrollee remained alert and oriented. The emergency department physical 
exam states the enrollee was afebrile with pulse, blood pressure, and respiratory rate as normal. The 
documentation has determined that the principal diagnosis, A41.9 Sepsis, unspecified organism was not 
supported by the documentation.  
 
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 the inpatient services provided September 10, 2021, to September 15, 2021 billed with principal diagnosis 
code A41.9.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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, we have confirmed that code 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2022 billed with 
codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. 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 
March 21, 2022 billed with codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, and 81351.