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

 
We decided that the Plan does not have to pay for the home infusions (99601 and 99602) provided on July 9, 
2021. 
 
You asked the Plan to pay for the home infusions (99601 and 99602). You say that the patient was served in 
good faith and the services should be paid at 100%. The Plan denied your request. The Plan says the billed 
codes are 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. 
 
In this case, the CPT Code Manual definition of code 99601 is home infusion/specialty drug administration, per 
visit (up to 2 hours). The CPT Code Manual definition of code 99602 is home infusion/specialty drug 
administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary 
procedure).  We find that CPT code 99601 and 99602 are not supported in the medical record. Specifically, CPT codes 
99601 and 99602 have a status indicator of B. This means that CPT codes 99601 and 99602 are considered 
bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of 
the home infusions (99601 and 99602) have not been met. Therefore, we decided that the Plan does not have to 
pay for the home infusions (99601 and 99602) provided on July 9, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve the repeat ESI services. You say that the enrollee does not receive narcotics 
from their practice and feels the requested injection services are the best solution for pain relief. You say that 
the clinical information provided supports this need. The Plan denied your request. The Plan says the 
documentation received shows the enrollee does not meet all the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI services may be considered medically 
reasonable and necessary when the medical record documents at least 50% sustained improvement for at least 3 
months or after 14 days using a different approach, level or medication when the enrollee failed to respond well 
to the initial ESI. 
 
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 repeat ESI services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the records show the 
enrollee received the last ESI on February 10, 2022. This injection shows to have provided 75-80% relief. A 
repeat epidural steroid injection is not medically reasonable and necessary at this time. 
 
 
 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 repeat ESI services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repeat epidural steroid injection (ESI) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on September 1, 
2021. 
 
You asked the Plan to pay for subsequent hospital care. You say that the enrollee was seen twice on this date 
by two providers with different specialties. The Plan denied your request. The Plan says a National Correct 
Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 99222 and 99232. This PTP edit 
has a modifier indicator of 0, meaning there are no modifiers that can bypass this edit. In addition, both providers who billed for these services on September 1, 2021, are part of the same hospital group and have an 
internal medicine specialty. 
 
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 99232 
is a column II code to column I code 99222. This code pair does not allow for a modifier to bypass the edit. 
These services were billed by two separate providers on the same date; however, both providers are within the 
same billing entity, and both have a primary taxonomy of 207R00000X  Internal Medicine. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for subsequent hospital care (99232) provided on September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair and related accessories. 
 
You asked the Plan to pre-approve the wheelchair and related accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment 
(DME) in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair and related accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve the wheelchair and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on August 12, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that you have provided medical records for this 
service, so this service should be covered. The Plan denied your request. The Plan says unauthorized, non-plan 
care is not covered. 
 
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. 
 You are not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found 
no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan 
does not have to pay for telehealth services provided on August 12, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for in-network urgent care, specialist office 
visits and services, computed tomography (CT) scan, and ultrasound provided on June 1, 2021 to October 13, 
2021. 
 You asked the Plan to waive the copayments for in-network urgent care, specialist office visits and services, 
computed tomography (CT) scan, and ultrasound. You say that you have lost work due to the pandemic and 
cannot afford these charges. The Plan denied your request. The Plan says the total amount charged for the 
various copayments 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 $65 
copayment for each Medicare-covered urgent care facility visit. 
 
Your contract with the Plan clearly says that you must pay a $45 copayment for physician specialist services. 
 
Your contract with the Plan clearly says that you must pay a $350 copayment for CT scans. You were asked to 
pay $171.66 for this service, which is less than the documented amount in the Plans EOC. 
 
Your contract with the Plan clearly says that you must pay a $350 copayment for diagnostic radiology other 
than CT scans. You were asked to pay $50 for this service, which is less than the documented amount in the 
Plans EOC. 
 
Please see chart below for a detailed list of all services rendered from dates of service January 1, 2021 to 
October 13, 2021. 
 
Date of Service 
Service 
Provided 
Allowed Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Responsibility 
June 1, 2021 Urgent Care $180 $65 copayment $65 
September 14, 2021 
Specialist office 
visit 
$260.91 $45 copayment $45 
September 15, 2021 
Specialist 
service (93356) 
$48.88 $45 copayment $45 
September 28, 2021 
Specialist office 
visit 
$132.97 $45 copayment $45 
September 28, 2021 CT scan $171.66 $350 copayment $171.66 
October 13, 2021 Ultrasound $105.84 $350 copayment $50 
   Total $421.66 
 
 
You have been asked to pay a total of $421.66 for in-network urgent care, specialist office visits and services, 
computed tomography (CT) scan, and ultrasound.  
 
In-network urgent care falls within the Urgently Needed Services benefit category. Specialist office visits and 
services fall within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. 
Computed tomography (CT) scans and Ultrasounds both 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 
in-network urgent care, specialist office visits and services, computed tomography (CT) scan, and ultrasound 
provided on June 1, 2021 to October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you have not tried and failed zoledronic acid. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. The provided documentation does not show evidence of you having 
tried and failed IV zoledronic acid. The provided documentation does not show evidence of you having a 
contraindication to zoledronic acid or likely to have more adverse effects or less effectiveness from zoledronic 
acid versus Prolia. Our physician reviewer found that your condition does not meet step therapy criteria for 
Prolia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 12, 2021.  
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 9, 2021. 
 You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on October 2, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim to be 
reprocessed because other claims have been processed and paid by the Plan. The Plan denied your request. The 
Plan says the non-contracted provider did not submit the RAP claim for services for the October 2, 2021 date 
of service until November 29, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, October 2, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on October 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 9, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you do not 
believe the claim was properly coded. You also say that it was your right to refuse medical services that you 
did not believe were required and necessary at the time of the incident. The Plan denied your request. The Plan 
says this service is not covered by Medicare because you refused transportation to the local hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 9, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 9, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that the criteria for coverage have 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 Injectafer. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found this elderly female (age 
81) has chronic anemia largely due to anemia of iron deficiency from chronic arteriovenous malformations. 
She gets periodic iron infusions, usually monthly. Elderly patient's poorly absorbed oral iron and due to the 
need to increase her hemoglobin at a more rapid rate oral iron would not be indicated. Her hemoglobin and 
ferritin have been dropping as has her iron sat. However, ferritin goes up signficantly with iron infusions which 
is why it is  >30 but has been steadily declining with the rate of her hemoglobin indicating iron deficiency. The 
use of intravenous iron is reasonable and medically necessary for this patient. It is safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have been met. Therefore, we decided that the Plan has to pre-
approve Injectafer.  
 
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 the laboratory services rendered on June 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the bone replacement graft (D7953), and guided 
tissue regeneration (D4266) provided on September 28, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say these services should be covered. The 
Plan denied your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft and guided 
tissue regeneration are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the bone replacement graft (D7953), and guided tissue regeneration (D4266) 
provided on September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from May 2, 2020, to 
May 6, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you have been hospitalized several 
times at the same facility and you have never been charged for self-administered drugs. You also say that you 
do not feel it is fair to have to pay for the self-administered drugs. The Plan denied your request. The Plan says 
self-administered drugs are not covered services under your plan. 
 
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 pay for the self-administered drugs 
provided from May 2, 2020, to May 6, 2020.  
 Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction and contact lens fitting provided on 
November 29, 2021. 
 You asked the Plan to pay for an eye refraction and contact lens fitting. The Plan denied your request. The Plan 
says the vision related services are not a covered by your medical plan. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Medicare and the Plan do not cover contact les 
fitting. Therefore, we decided that the Plan does not have to pay for an eye refraction and contact lens fitting 
provided on November 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
October 1, 2021 to October 19, 2021. 
 
You asked the Plan to pay for home health services. You say that there was not enough time to send the 
information in. The Plan denied your request. The Plan says they did not receive a RAP claim within five days 
of the start of service. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not support that the RAP was submitted within 5 calendar days after the start of care.. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from October 
1, 2021 to October 19, 2021.