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

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from October 1, 
2021, through October 31, 2021. 
 
You asked the Plan to pay for home infusion therapy (S9328). You say that you have attached the primary 
Explanation of Benefits that shows the enrollee is responsible for $215.76 coinsurance. You say that you were 
underpaid. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes. 
 
  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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy (S9328) have not been met. Therefore, we decided that the Plan does not 
have to pay for home infusion therapy (S9328) provided from October 1, 2021, through October 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the ultraviolet therapy (CPT code 97028) provided 
from December 18, 2021, through January 25, 2022. 
 
You asked the Plan to reimburse for the ultraviolet therapy. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says the claim was processed accordingly with the 
enrollee's 2021 and 2022 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The request for reimbursement was processed according to the Medicare Fee Schedule 2021 and 2022 
according to the date of service. The rules say that for services of a non-contracting, original Medicare, 
participating provider; there is no balance billing paid by either the plan or the enrollee. Therefore, we decided 
that the Plan does not have to reimburse for the ultraviolet therapy (CPT code 97028) provided from December 
18, 2021, through January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CologuardTM colorectal cancer screening (81528) 
provided on December 14, 2021. 
 
You asked the Plan to pay for the CologuardTM test. You say that you would like this claim reprocessed and 
approved for payment as it is eligible for Medicare payment. The Plan denied your request. The Plan says there 
is insufficient information to verify that Medicare criteria for this service. 
 
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 the CologuardTM colorectal cancer 
screening (81528) provided on December 14, 2021, have been met. Specifically, no medical records were 
provided to verify that the criteria for coverage of this screening have been met. It is also unclear what provider 
referred these services for the enrollee. Therefore, we decided that the Plan does not have to pay for the 
CologuardTM colorectal cancer screening (81528) provided on December 14, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on July 29, 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 that the procedure code is not supported in the records submitted. 
 
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 27397 is "Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); 
multiple tendons." 
 
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 the records do support that CPT 
27397- transplant or transfer (with muscle redirection or rerouting), thigh (e.g., extensor to flexor); multiple 
tendons- was rendered in this case. The operative procedure notes that the piriformis tendon, conjoined tendon 
the short external rotators, quadratus femoris, and the superior most fibers of the gluteus maximus were 
released off the posterior aspect of the proximal femur. Vastus lateralis was released proximally, and tagged for 
retraction and for later repair. Maintaining a wide margin, the dissection continued proximally, transecting the 
distal aspects of the gluteus medius and minimus immediately proximal to the soft tissue mass. After the 
hemiarthroplasty, the vastus lateralis was advanced to its native tension and tied through the holes upon the 
lateral aspect of the proximal femoral component. Similarly, the gluteus medius and minimus, as well as 
piriformis and the conjoined tendon of the short external rotators were advanced, and were tied to the implant 
through the holes. 
 
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 
surgical services provided to the enrollee on July 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight wheelchair (CPT code K0003) provided on 
March 20, 2021. 
 
You asked the Plan to pay for the lightweight wheelchair. You say that the claim should be paid. The Plan 
denied your request. The Plan says the billed services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Healthcare Common Procedure Coding System (HCPCS) code K0003-RR-99-KJ-KX (1 Unit) remains not 
supported. HCPCS code K0003 represents Lightweight wheelchair. The documentation indicates that Standard 
hemi (low seat) wheelchair was supplied. There is a more appropriate HCPCS code (HCPCS K0002) that 
should be used to bill for a Standard hemi (low seat) wheelchair. It is noted that multiple attempts were made to 
contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for the 
lightweight wheelchair (CPT code K0003) provided on March 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit with a specialist (99213, 99214) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visit with a specialist. You say that you have chronic kidney disease, 
and you need to see a specialist. The Plan denied your request. The Plan says the service you requested is not 
covered by the Plan if given without a referral from your primary care provider. Your plans EOC states that 
you may need a referral from your primary care provider to see a specialist. 
 
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 
office visit with a specialist (99213, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Contour Next Test Strips. 
 You asked the Plan to pre-approve the Contour Next Test Strips. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan may specific certain DME as preferred 
and subject to the criteria listed in the Medicare rules section. 
 
We looked at the file and Medicare rules. In this case, the medical records do not discuss why you would not be 
able to use the Plans preferred brand of test strips. Based on this information, we decided that Medicare rules 
for coverage of the Contour Next Test Strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Contour Next Test Strips.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on February 7, 
2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that this is a preventative service and 
should not have a copayment. The Plan denied your request. The Plan says the copayment applied was 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 $340 
copayment for Medicare-covered visit to a hospital facility, ambulatory surgical center, or outpatient hospital 
facility. 
 
You have been asked to pay a $340 copayment for an endoscopy. An endoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an endoscopy provided on February 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74176) provided October 23, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed is not supported in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 74176 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 74176. Based on this information, we decided that Medicare rules for coverage of 
the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for 
radiology services (74176) provided October 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 31, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service January 31, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this procedure will relieve the enrollee's pain. 
The Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that 
this is an appropriate procedure for the enrollee's back pain. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and will 
benefit to transfer to a LTACH facility. The Plan denied your request. The Plan says the enrollee's needs are 
being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a significant past medical history of diabetes mellitus, bilateral lower 
extremity wounds, and obesity who was hospitalized on 7/13/2022 with septic shock associated with right 
lower extremity wound gangrene. The wound care noted on 7/25/2022 states the enrollee is in no acute distress 
and is tolerating intravenous antibiotics and wound care. The enrollee is receiving appropriate care at the 
present setting. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care.  
  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the medical eye exam (92014) provided on March 28, 2022. 
 
You asked the Plan to pay for the medical eye exam. You say that you did not know the Plan would not pay for 
this service. The Plan denied your request. The Plan says that your supplemental benefit covers a maximum of 
one routine eye exam per calendar year. You had a previous eye exam on March 9, 2022, which exhausted this 
benefit. 
 
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 denied payment for this service on the basis that you have already had 
a routine (non-medical) eye exam in 2022. However, the Plan has not provided any argument or explanation as 
to why this claim was not processed under your medical benefits. Code 92014 is defined as a medical 
examination and evaluation, ophthalmological service, and although the original claim was not forwarded to us 
for review, the diagnosis indicated on the case files reconsideration background data form is a medical 
diagnosis (dry eye syndrome of bilateral lacrimal glands (H04.123). The Plan has not made reasonable and 
diligent efforts to support the denial of this claim under your medical benefit. Therefore, we decided that the 
Plan has to pay for the medical eye exam (92014) provided on March 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90999, A4657, and J0882 billed on January 
31, 2022. 
 
You asked the Plan to pay for procedure codes 90999, A4657, and J0882. You say that this was the initial 
claim and payments were never received. The Plan denied your request. The Plan says the provider cannot bill 
Type of Bill 72X with J0882 code and report a value of 99.99 in value code 48 or 49. 
 
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 90999 is unlisted dialysis procedure, inpatient or 
outpatient. The CPT Code Manual definition of code A4657 is syringe, with or without needle, each. The CPT 
Code Manual definition of code J0882 is injection, darbepoetin alfa, 1 microgram (for esrd on dialysis). 
 
We find that CPT codes 90999, A4657, and J0882 are not supported in the medical record. Specifically 
reporting the value 99.99 is not permitted when billing ESAs. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 90999, A4657, and J0882 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 90999, A4657, and J0882 billed on January 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for an eptinezumab infusion 
provided on February 18, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the infusion. You say that this service should 
be covered by Medicare. The Plan denied your request. The Plan says the correct copayment and coinsurance 
were applied. 
 
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 $225 
copayment for surgery or other services provided at an outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay $185.70, which is less than the $225 copayment for the infusion. The infusion falls 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. You have also been asked to pay $960.36, which is 20% of the 
allowed amount for the eptinezumab ($4,801.80 allowed amount x 20% coinsurance = $960.36). The 
eptinezumab falls within the Medicare Part B Prescription Drugs benefit category. The total for the visit is 
$1,146.06. 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 and coinsurance for an eptinezumab infusion 
provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and drug testing provided on January 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and drug testing. You say that the claim was denied because it 
was assumed that a nurse practitioner saw the enrollee when the physician saw the enrollee. The Plan denied 
your request. The Plan says no prior authorization was 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 
office visit and the drug testing. We found no exception that would require the Plan to pay for the office visit 
and the drug testing. The record shows the physician was out-of-network. Therefore, we decided that the Plan 
does not have to pay for the office visit and drug testing provided on January 25, 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 diagnostic testing and specialist visit provided on March 
15, 2022, to March 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic testing and specialist visit provided by an OON provider. You say 
that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
the services received were neither emergent nor urgent and prior authorization was not obtained to seek 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 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 diagnostic testing and specialist visit provided 
on March 15, 2022, to March 28, 2022, by an out-of-network (OON) provider.