Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from July 21, 2021, to 
July 22, 2021. 
 
You asked the Plan to pay for outpatient hospital care. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says the payment for these 
services is bundled into the inpatient hospital admission which began on July 25, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient services are not separately payable 
when they are provided within three days preceding a related inpatient hospital stay by the same entity. 
 
We looked at the file and Medicare rules. The records show that both the outpatient hospital services and the 
inpatient hospital admission were billed with a primary diagnosis of J18.9 (pneumonia, unspecified organism). 
This means that the two admissions are related. Because the outpatient services were received within three days 
of the inpatient hospital admission, this means that they are not separately payable by Medicare rules. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided from July 21, 
2021, to July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88305, 88312) provided on March 23, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory services (88305, 88312) provided on 
March 23, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services provided from April 7, 
2021, to December 27, 2021. 
 
You asked the Plan to waive the copayments for the lab services. You say that you were informed there would 
be no copayments for the labs. The Plan denied your request. The Plan says you have been 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 a $10 
copayment per day for laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for each of the 3 visits for lab services. The total for the visits is 
$30. The lab services fall 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 copayments for laboratory services provided from April 7, 
2021, to December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 18, 2021. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date of service 
in question, so Original Medicare is responsible for this claim. 
 
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 medical services provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing (G0482) provided on January 28, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory drug testing (G0482) provided on 
January 28, 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 intravenous infusion therapy (96365) provided on 
February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the intravenous infusion therapy. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 intravenous infusion therapy (96365) provided 
on February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radicava Ors. 
 
You asked the Plan to pre-approve Radicava Ors. You say that the medication is necessary. The Plan denied 
your request. The Plan says there are in-network providers that are able to provide these services. Therefore, 
coverage criteria have not been met. 
 
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 Radicava Ors.  
 
Benefits for Radicava Ors 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 outpatient dermatology office visit (99213) provided 
April 4, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are appealing for the denied office visit charge. 
The Plan denied your request. The Plan says use of modifier not supported by the claim. 
 
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 99213 is established patient office or other outpatient 
visit, 20-29 minutes 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, the plan had made several 
attempts to obtain a corrected claim from the provider without success. Based on this information, we decided 
that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does 
not have to pay for the outpatient dermatology office visit (99213) provided April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound guidance for vascular access (76937) 
intravascular ultrasound (37252) transcatheter placement of intravascular stent(s), cervical carotid artery 
(37215) provided February 23, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that please review the medical records and 
process the claim for payment. The Plan denied your request. The Plan says CPT code 76937 and 37252 were 
billed without an appropriate primary code and not performed by the same practitioner on the same date of 
service. A valid clinical trial not billed on the claim for CPT code 37215. 
 
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 the 
surgical procedure is an add-on code and has not been billed with an appropriate primary procedure code. Also 
a valid clinical trial not billed on the claim for CPT code 37215. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for ultrasound 
guidance for vascular access (76937) intravascular ultrasound (37252) transcatheter placement of intravascular 
stent(s), cervical carotid artery (37215) provided February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig, any type (A9282) and sales tax (S9999) purchased 
July 7, 2021. 
 
You asked the Plan to pay for the wig. You say that you are requesting reimbursement for 2 wigs you 
purchased due to hair loss from chemotherapy. The Plan denied your request. The Plan says this is not covered 
under the Plan benefits under any normal circumstances. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig, any type 
(A9282) and sales tax (S9999) purchased July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee from April 4, 2019, 
to May 2, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 11011: 
 
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation 
(eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle 
 
CPT 15275: 
 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, 
and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 
 
CPT 26340: 
 
Manipulation, finger joint, under anesthesia, each joint 
 
CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: A comprehensive history; A comprehensive examination; and 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 presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function 
 
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 not supported by the medical records. Our reviewer found that there was a consult for surgery on 
date of service 4/3/19 by the emergency room physician, where the decision for surgery was made. For the first 
date of service - 4/4/19 - the medical provider should not have billed for the office visit. The Medically 
Unlikely Edits (MUE) for CPT 15275 is only one, but the units billed were two. This is a violation of the 
coding guidelines. MUE was also extended for CPT 26418, as five were billed, but the MUE is 4. The 
procedure code for date of service 5/2 with procedure code 14301 has a 90 day global from 4/4 and medical 
records do not support the use of modifiers indicating a modifier is required for payment. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee from April 4, 2019, to May 2, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one. 
 
You asked the Plan to pre-approve Gel-one. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Gel-one. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. In this case, the patient 
has not tried and failed the required drugs. There is no documentation provided indicating that the Plans 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one.
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 March 
3, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were informed there 
would be no copayment for the visit. The Plan denied your request. The Plan says you have been 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 a $20 
copayment for specialist visits.  
 
You have been asked to pay a $20 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a nuclear stress test provided on March 1, 2022. 
 
You asked the Plan to waive the cost for a nuclear stress test. You say that if you had been made aware of the 
cost you would not have had this test done. The Plan denied your request. The Plan says the costs applied were 
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 20% 
coinsurance for durable medical equipment, a 20% coinsurance for Part B drugs, and $69.41 copayment for a 
stress test for outpatient diagnostic tests.  
 
 
 
 
 
 You have been asked to pay $168.44 cost for a nuclear stress test. A nuclear stress test falls within the 
outpatient diagnostic test 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 for a nuclear stress test 
provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on February 
4, 2022. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you required this item in order to 
go to medically necessary appointments.  You said that network providers didn't have this item in stock, so you 
had to purchase it from an out-of-network vendor. The Plan denied your request. The Plan says this item is not 
covered because it is for use outside the home.  The Plan also says that only rented, not purchased, oxygen 
equipment is covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The item at issue in this appeal is for use outside of the home. The Plan has 
already provided you with stationary and portable oxygen systems for use inside your home. Although this item 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on February 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmologist services (92014, 92134, 92202) provided on 
February 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmologist services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 ophthalmologist services (92014, 92134, 92202) 
provided on February 7, 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 (S9122) provided on April 1, 2021 to 
July 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial and the services were medically necessary. The Plan denied your request. The Plan 
says the services denied correctly as they were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 (S9122) provided on April 1, 
2021 to July 4, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha syringe. 
 
You asked the Plan to pre-approve Repatha syringe. You say that the medication is necessary. The Plan denied 
your request. The Plan says there are in-network providers that are able to provide these services. Therefore, 
coverage criteria have not been met. 
 
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 Repatha syringe.  
 
 
 
 
 Benefits for Repatha syringe may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.