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

 
We decided that the Plan has to pay for surgical services (procedure code 29826) provided to the enrollee on 
August 17, 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 denied code remains 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. 
 
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 the medical records do substantiate 
that arthroscopy, shoulder surgical: decompression of subacromial space with partial acromioplasty with 
coracoacromial ligament release, when performed - CPT 29826 - was rendered in this case. The enrollee was 
being treated for complete rotator cuff tear or rupture of left shoulder, not specified as traumatic; impingement 
syndrome of left shoulder; strain of muscle, fascia, and tendon of other parts of biceps, left arm initial 
encounter; and superior glenoid labrum lesion left shoulder. The 8/17/21 operative report corroborated the 
significant bursitis, it was elected to proceed with a soft tissue subacromial decompression and bursectomy. 
The soft tissue from the undersurface of the acromion was removed. The thickened coracoacromial ligament 
was recessed along the undersurface of the acromion (with an ArthroCare wand.) The remaining acromion did 
not impinge on the rotator cuff, with range of motion in all planes including forward flexion. Therefore, the 
medical records do substantiate that CPT 29826 was rendered in this case. 
 
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 (procedure code 29826) provided to the enrollee on August 17, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from August 31, 2021, to 
September 1, 2021. 
 
 You asked the Plan to pay for the inpatient services. You say that these services were necessary, and this claim 
was billed appropriately. The Plan denied your request. The Plan says this claim was billed with a clinical trial 
procedure, procedure 02RF38Z  Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous 
Approach, and was not billed with a clinical trial number. The inpatient facility claim is missing this necessary 
piece of information, and a corrected claim is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. * 
 
We find that these services were not billed/reported to Medicare standards. Specifically, the record indicates 
that a TAVR procedure was rendered on the billed date of service. Medicare offers TAVR under CED. It is 
mandatory to report a clinical trial number on all claims for services provided under CED. The claim submitted 
does not include a clinical trial number. Based on this information, we decided that Medicare rules for coverage 
of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital care provided from August 31, 2021, to September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the lightweight wheelchair (WC) rental billed with date of service April 
1, 2021. 
 
You asked the Plan to pay for the WC rental. You say that the code K0003 is a covered services under 
Medicare and the Plan. The Plan denied your request. The Plan says that the file does not include information 
to show that coverage criteria have been met, such as the order or medical records. 
 
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. This claim is for a subsequent month's rental for the WC, either the fourth month 
or beyond. The Plan provided no information as to whether the prior months' rental charges were paid. In 
addition, though the supplier did not submit supporting documentation, such as the order or visit notes, the 
claim for this rental was denied stating that the Plan does not cover this item. The supplier appropriately 
responded that this is a covered services per the Plan's policies. Although the Plan did request additional 
information to support this claim, the request was sent to the ordering physician, and not the appealing 
equipment supplier. We find that denial of this claim due to missing documentation is not supported when the 
Plan did not do its due diligence in requesting the documentation from the appellant. Therefore, we decided 
that the Plan has to pay for the lightweight wheelchair (WC) rental billed with date of service April 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve Emgality. You say that the enrollee suffers from daily migraines. You say 
that it is in the enrollee's best interest and safety that he uses the requested drug. You say that it is crucial that 
the enrollee maintain the intended regimen prescribed to avoid harm. The Plan denied your request. The Plan 
says the enrollee does not have pharmacy benefits administered under this contract. The Plan says that the 
enrollee does have TRS-CARE MA, which provides its own pharmacy benefits. 
 
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 Emgality.   
Benefits for Emgality 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037M) rendered by 
the out-of-network (OON) provider on September 6, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis (0037M) rendered by the out-of-network 
(OON) provider on September 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these lab services correctly. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on September 21, 
2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered. 
The Plan denied your request. The Plan says the deductible applied correctly based on the services provided, 
your deductible applies when these services are performed out-of-network. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,500 deductible which applies to out-of-network outpatient mental 
health care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category out-of-
network outpatient mental health care. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1,500 deductible which applies to out-of-network outpatient mental health care. This 
cost sharing is a contractual obligation that had not been met at the time the office visit was received on 
September 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office 
visit provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the post-discharge meal service. 
 
You asked the Plan to pre-approve the post-discharge meal service. You say that you would like 
reconsideration because the enrollee meets criteria for this benefit. The Plan denied your request. The Plan says 
the diagnosis on the enrollee's discharge statement is not congestive heart failure. 
 
Medicare generally does not cover meal delivery services. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We looked at the file and rules. Based on this information, we decided that Medicare rules for coverage of the 
post-discharge meal service have not been met. Specifically, the record does not indicate that the enrollee was 
discharged with a diagnosis of congestive heart failure. Therefore, we decided that the Plan does not have to 
pre-approve the post-discharge meal service.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services on November 
2, 2021. 
 
You asked the Plan to waive the copayment for Emergency Room Services. You say that you do not feel that 
you should be responsible for this copayment due to them not providing care to her at the emergency room. 
The Plan denied your request. The Plan says the emergency room copayment applied correctly per the 
Evidence of Coverage. 
 
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 $50 
copayment for Emergency Room Services.  
 
 You have been asked to pay a $50 copayment for Emergency Room Services. Emergency Room Services falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Emergency 
Room Services on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic metabolic panel (80048), venipuncture (G0471) and 
travel allowance (P9604) provided on October 20, 2021. 
 
You asked the Plan to pay for the basic metabolic panel, venipuncture and travel allowance. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is 
a duplicate claim. 
 
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 basic metabolic panel (80048), 
venipuncture (G0471) and travel allowance (P9604) provided on October 20, 2021. have been met. 
Specifically, the record shows that the Plan processed and paid CPT codes 80048, P9604 and G0471 for the 
same provider and same date of service. The documentation does not support that these services were rendered 
multiple times on the same date of service. Therefore, we decided that the Plan does not have to pay for the 
basic metabolic panel (80048), venipuncture (G0471) and travel allowance (P9604) provided on October 20, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a prostate biopsy on October 8, 2021. 
 
You asked the Plan to waive the copayment for prostate biopsy. You say that the amount should be $150 and 
that you were not admitted to the hospital. The Plan denied your request. The Plan says the copayment 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 $250 
copayment for an In-Network prostate biopsy.  
 
You have been asked to pay a $250 copayment for an In-Network prostate biopsy. A Prostate biopsy falls 
within the 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 a prostate biopsy on October 8, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the magnetic resonance imaging (MRI) rendered on 
July 24, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were told you were getting an x-ray 
rather than an MRI. The Plan denied your request. The Plan says that the copayment applied is correct. 
 
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 did not send us the applicable Evidence of Coverage for your contract 
with the Plan. Without the Evidence of Coverage, we cannot determine whether any cost-sharing benefit 
applies to magnetic resonance imaging MRI scans or if the cost-sharing amount you are being asked to pay is 
correct. Therefore, the Plan has not shown that its decision to ask you to pay $194.10 for this MRI is correct or 
justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan has 
to waive the copayment for the magnetic resonance imaging (MRI) rendered on July 24, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76641), digitial breast tomosynthesis 
(77063) and screening mammography (77067) provided on October 13, 2021. 
 
You asked the Plan to pay for the breast ultrasound, digital breast tomosynthesis and screening mammography. 
You say that you would like reconsideration because this provider diagnosed your cancer and you rely on him 
for yearly testing. The Plan denied your request. The Plan says this provider has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the breast 
ultrasound (76641), digitial breast tomosynthesis (77063) and screening mammography (77067) provided on 
October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
You asked the Plan to pre-approve a power scooter. You say that you cannot go anywhere without a scooter. 
The Plan denied your request. The Plan says a home evaluation was not provided. 
 
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 looked at the file and the rules. The file shows that your condition can be improved by a walker. The 
records do not show that your home provides adequate access, maneuvering space, and surfaces for operation. 
This means that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 7, 2021, through November 15, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $325 per 
day, for days 1-5 for each Medicare-covered hospital admission.  
 
 
 You have been asked to pay $1,625 ($325 copayment x 5 days) for the Medicare-covered inpatient hospital 
care provided. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 7, 2021, through November 15, 2021.