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

 
We decided that the Plan does not have to pay for a shoulder injection (20610) and fluoroscopic guidance for 
needle placement (77002) provided on December 8, 2021. 
 
You asked the Plan to pay for a shoulder injection and fluoroscopic guidance for needle placement. You say 
that you have provided records to support the services billed. The Plan denied your request. The Plan says rules 
for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not allow separate payment for an 
additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior 
procedure and if billed without modifier -58, -78, or -79. 
 
We looked at the file and Medicare rules. In this case, the record shows that a shoulder injection was provided 
during the postoperative period of a prior procedure. A shoulder injection was billed without an appropriate 
modifier. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 77002 indicating fluoroscopic guidance for 
needle placement is an add-on code and has not been billed with an appropriate and payable primary procedure 
code. Based on this information, we decided that Medicare rules for coverage of a shoulder injection and 
fluoroscopic guidance for needle placement have not been met. Therefore, we decided that the Plan does not 
have to pay for a shoulder injection (20610) and fluoroscopic guidance for needle placement (77002) provided 
on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardio screen analysis coded as 81401, 81403, 
81404, 81405, 81406, 81407 and 81408 provided January 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. 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. 
 In this case, we find that CPT codes 81401, 81403, 81404, 81405, 81406, 81407 and 81408 are not supported 
in the medical record. Specifically, there is not Medicare benefit for screening CV risk assessment testing for 
asymptomatic patients. Screening asymptomatic patients for cardiovascular risk is statutorily excluded by 
Medicare. Additionally, the state where the provider performed the service differs from the state where the 
enrollee resides. The provider is located in Florida, while the enrollee resides in Louisiana. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the hereditary cardio screen analysis coded as 
81401, 81403, 81404, 81405, 81406, 81407 and 81408 provided January 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation states that the enrollee does not have skilled therapy needs after an evaluation by the physical 
therapist. In this case, the enrollee may benefit from skilled nursing to monitor blood pressure medication 
management. However, there is no documentation to show that the enrollee would require daily skilled therapy 
thus criteria have not been met for daily skilled services in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Enhertu. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the National Comprehensive Cancer Network 
has stated that the requested drug is indicated as second-line therapy and may be considered as first-line 
therapy for select patients (ie, those with rapid progression within 6 months of neoadjuvant or adjuvant 
therapy). The record indicates that the enrollee satisfies these conditions. The elements of the coverage criteria 
are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have been met. Therefore, we decided that the Plan has to pre-approve 
Enhertu.  
 
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 wound debridement services (11042) provided on February 
1, 2022 and March 1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound debridement 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 wound debridement services (11042) provided on 
February 1, 2022 and March 1, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the $225 copayment for outpatient surgery performed on 
March 9, 2022. 
 
You asked the Plan to lower the $225 copayment for outpatient surgery performed on March 9, 2022. You say 
that you only be responsible for a $25 copayment for a specialty physician in-network office visit. The Plan 
denied your request. The Plan says you must pay a $225 copayment for outpatient surgery services. 
 
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 Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $225 copayment for outpatient surgery. Outpatient surgery 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 lower the $225 copayment for outpatient surgery 
performed on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on April 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the provider told you they were in-network and 
would take care of needed referrals. The Plan denied your request. The Plan says the service was provided out-
of-network and was not approved in advance. 
 
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 outpatient visit provided on April 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an injection of anesthetic or steroid (64448) and related services 
provided from April 15, 2021, to April 19, 2021. 
 
You asked the Plan to pay for an injection of anesthetic or steroid. You say that you have provided medical 
records to support the services at issue. The Plan denied your request. The Plan says that rules for payment 
have not been met. 
 
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. Specifically, the Plan denied the claim because procedure code 64448 must be 
billed with an applicable device code. The case record indicates that the claim was corrected and resubmitted. 
The Plan has not provided information to explain why the claim remains denied. 
 
It is the Plan's responsibility to substantiate its denial. In this case, the Plan's denial has not been substantiated, 
so we must rule in your favor. Therefore, we decided that the Plan has to pay for an injection of anesthetic or 
steroid (64448) and related services provided from April 15, 2021, to April 19, 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 critical care, first hour (99291) provided on December 17, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. A time based code like 99291 cannot be verified in this case. Based on this 
information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care, first hour (99291) provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit, therapeutic injections, Part B 
drugs, lab services and physical therapy visit provided from January 4, 2022, to February 18, 2022. 
 
You asked the Plan to waive the cost share for the office visit, therapeutic injections, Part B drugs, lab services 
and physical therapy visit. You say that these charges should be covered. The Plan denied your request. The 
Plan says the cost share 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 20% 
coinsurance for Medicare Part B drugs, $5 copayment for lab services, $40 copayment for physical therapy 
visits and $35 copayment for physician specialist services from an in-network provider.  
 
You have been asked to pay $2,449.03 for the office visit, therapeutic injections, Part B drugs, lab services and 
physical therapy visit. 
 
Date of Service Service Allowed Amount Cost Share Member Liability 
January 4, 2022 Therapeutic Injection $120.33 $35 copayment $35 
January 5, 2022 Office Visit $134.30 $35 copayment $35 
January 11, 2022 Therapeutic Injection $200.55 $35 copayment $35 
January 11, 2022 Part B Drugs $5,397.62 20% coinsurance $1,079.52 
January 18, 2022 Therapeutic Injection $122.94 $35 copayment $35 
January 25, 2022 Therapeutic Injection $122.94 $35 copayment $35 
February 1, 2022 Therapeutic Injection $204.90 $35 copayment $35 
February 1, 2022 Part B Drugs $5,222.56 20% coinsurance $1,044.51 
February 8, 2022 Therapeutic Injection $122.94 $35 copayment $35 
February 9, 2022 Lab services $8.07 $5 copayment $5 
February 15, 2022 Therapeutic Injection $122.94 $35 copayment $35 
February 18, 2022 Physical Therapy Visit $57.04 $40 copayment $40 
TOTAL:    $2,449.03 
 
Part B drugs fall within the Medicare Part B Prescription Drugs benefit category. Lab services fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Physical therapy visits fall 
within the Outpatient Rehabilitation Services benefit category. Office visits and therapeutic injections fall 
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 cost share for the office visit, therapeutic injections, Part B drugs, lab services and 
physical therapy visit provided from January 4, 2022, to February 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
January 4, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. A time-based code cannot be verified without this information. Based on this 
information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service January 
4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation provided on February 25, 
2022, billed with code 85060. 
 
You asked the Plan to pay for the blood smear interpretation. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says this code is not payable for services provided in the 
outpatient hospital setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 85060 has a Pro/Tech flag of 8. This indicator identifies the professional component of clinical 
laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear 
for hospital inpatient. No payment is recognized for codes 88141, 85060 or code P3001-26 furnished to 
hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory 
fee schedule payment for the clinical laboratory test. Based on this information, we decided that Medicare rules for coverage of the blood smear interpretation have not been met. Therefore, we decided that the Plan does not 
have to pay for the blood smear interpretation provided on February 25, 2022, billed with code 85060.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services (97803) provided on 
November 29, 2021. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that these services were medically 
necessary and reasonable. The Plan denied your request. The Plan says these services are only covered for 
enrollees with renal disease or diabetes. Neither the medical records nor the billed claim indicates that the 
enrollee has either diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services (97803) provided on November 29, 2021.
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 
December 20, 2021, to December 21, 2021. 
 
You asked the Plan to waive the copayment for inpatient care. You say that you should not be responsible for 
this copayment, as this inpatient admission could have been avoided. The Plan denied your request. The Plan 
says this claim was processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $300 
copayment for each of the first five days of an inpatient hospital admission. The day before you are discharged 
counts as your last inpatient day. 
 
You have been asked to pay a $300 copayment for a two-day inpatient hospital stay. 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 December 20, 2021, to December 21, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2022, billed with 
codes 1206, 81235, 81292, 81301 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 
January 31, 2022, billed with codes 1206, 81235, 81292, 81301 and 81321.