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

 
We decided that the Plan does not have to pay for the extracorporeal photopheresis services provided on May 
21, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee developed airway obstruction 
consistent with bronchiolitis obliterans. The Plan denied your request. The Plan says the service is not covered 
per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that extracorporeal photopheresis is only covered 
under certain medical indications. 
 
We looked at the file and Medicare rules. The file shows that the enrollee received the services at issue due to 
chronic bronchitis. The records do not indicate the enrollee had a condition that is indicated for coverage. 
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the extracorporeal photopheresis services 
provided on May 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found based on the medical records provided the complexity of your nursing, medical 
and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement of bone, which includes 
the epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed (11044), provided from May 3, 
2021. 
 
You asked the Plan to waive the copayment for the debridement of bone, which includes the epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed. You say that you never pay a fee for this service, just 
the copayment for an office visit. You also say you do not agree with paying this bill for the provider to clean 
and bandage with a gauze pad on a weekly basis, and someone is over charging. The Plan denied your request. 
The Plan says you were charged the correct copayment 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 $250 
copayment per visit for outpatient surgery or procedure at a hospital facility.  You have been asked to pay a $250 copayment for the debridement of bone, which includes the epidermis, 
dermis, subcutaneous tissue, muscle and/or fascia, if performed. The debridement of subcutaneous tissue falls 
within the Outpatient Surgery, including services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the debridement of 
bone, which includes the epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed (11044), 
provided from May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 8, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator/electro-acupuncture device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is considered experimental, investigational, and unproven for peripheral 
nerve stimulation. 
 
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is 
not a covered Medicare benefit. 
 
Medicare does not provide coverage for devices that function as auricular stimulators or electro-acupuncture 
devices. Based on this information, we decided that Medicare rules for coverage of the device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator/electro-
acupuncture device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-rays provided on May 5, 2021, and June 
23, 2021. 
 
You asked the Plan to waive the copayments for X-rays. You say that you disagree with the charges because 
you feel that the should be included under a surgical procedure you received. The Plan denied your request. 
The Plan says the claims were processed correctly and you are being charged the correct 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 $0 
copayment for X-rays provided by a primary care physician and a $35 copayment for X-rays provided by any 
other type of physician. 
 
You received X-rays on May 5, 2021, and June 23, 2021. X-rays are not included in follow-up visits and are 
subject to cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $34.77 per each 
X-ray for the total amount of $69.54, which is less than the total copayment amount.   
 
You have been asked to pay the total copayment amount of $69.54 for X-rays. X-rays 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 X-rays provided on May 5, 2021, and June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine provided on July 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that this should be a covered benefit. The Plan 
denied your request. The Plan says the shingles vaccine is not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services 
provided. The Plan follows the same rules.  
 
We looked at the file and the rules. The records do not show that you have been injured or directly exposed to 
any illness related to the services provided. Therefore, we decided that the Plan does not have to pay for the 
Shingles vaccine provided on July 1, 2021.  
 
Benefits for the services provided 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthoses provided from April 15, 2021 through 
May 6, 2021. 
 
You asked the Plan to pay for the orthoses. You say that proof of delivery and medical records have been 
provided for review. The Plan denied your request. The Plan says that there is no medical record included to 
support that the member had a face to face examination within six months of the written order for Durable 
Medical Equipment (DME) items. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order, proof of delivery and relevant medical records.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the ankle orthoses provided from 
April 15, 2021 through May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmic biometry by partial coherence interferometry 
with intraocular lens power calculation (92136) provided on May 11, 2021. 
 
You asked the Plan to pay for the ophthalmic biometry. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service 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 92136 is ophthalmic biometry by partial coherence 
interferometry with intraocular lens power calculation  
 
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 ophthalmic biometry. Our reviewer says that CPT code 
92136 does not meet criteria for billing or reimbursement consideration. Our reviewer found the record 
documents two different dates of service, March 23, 2021 and May 11, 2021. The dates of service cannot be 
confirmed, and therefore would not be covered. 
 
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 ophthalmic biometry have not been met. Therefore, we decided that the Plan 
does not have to pay for the ophthalmic biometry by partial coherence interferometry with intraocular lens 
power calculation (92136) provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from June 
22, 2021, to August 3, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received Medicare Part B drugs from June 22, 2021, to August 3, 2021. Therefore, you are responsible to 
pay your share of the cost-sharing charges. Please see the chart below.   
 
Date of Service Service Allowed Amount Amount You Owe 
6/22/2021 Medicare Part B Drugs $10,006.00 $2,001.20 
7/13/2021 Medicare Part B Drugs $10,156.00 $2,031.20 
8/3/2021 Medicare Part B Drugs $10,156.00 $2,031.20 
 
The total amount you owe is: $6,063.60.  
 
You have been asked to pay the total coinsurance amount of $6,063.60 for Medicare Part B drugs. Medicare 
Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided from June 22, 2021, to August 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 27, 2020, to May 1, 2020. 
 
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 payment of DRG 193 is not supported, as a review of the records support DRG 194 instead. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 193 (simple pneumonia and pleurisy with 
major complication or comorbidity). The plan updated to DRG 194 (simple pneumonia and pleurisy with 
complication or comorbidity). 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 pay for the services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found the review has determined that the records did not support the provider's reporting of DRG 193. 
The plan's alternate DRG 194 is correct. There were no arterial blood gas results documented. While the 
enrollee presentation warranted consideration for acute respiratory failure with hypoxia as a diagnosis there 
was no PaO2 <60 and no SpO2 < 91%. There was no documentation of treatment consistent with acute 
respiratory failure, such as administration of oxygen = 5L NC, or the provision of bilateral positive airway 
pressure (BiPAP) and/or mechnical ventilation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 27, 2020, to May 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee has severe Alzheimer's/Dementia and normally does not talk or walk. The Plan denied your request. The Plan says the enrollee does not appear to meet the criteria for admission to a SNF because the enrollee does not require two skilled services, nor can the enrollee meaningfully participate in therapy. The Plan states there are no skilled nursing needs and alternatives to admission to skilled nursing includes: readmission to the assisted living facility memory unit, long term care, or a dementia care unit.
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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near their baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on August 4, 
2021, and August 30, 2021. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges 
because a nurse changed the tubing not a physician. The Plan denied your request. The Plan says the claims 
were processed correctly, and you are being charged the correct 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 $40 
copayment for specialist visits. 
 
The medical records show that you received specialist services on August 4, 2021, and August 30, 2021. 
Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $80.   You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on August 4, 2021, and August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95908), short-latency 
somatosensory evoked potential study (95927) and electroencephalogram (95955) provided on February 15, 
2021. 
 
 
 
You asked the Plan to pay for the nerve conduction studies, somatosensory study and electroencephalogram. 
You say that you would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the documentation submitted does not support the services 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 95908 is nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95927 is short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or 
head. 
The CPT Code Manual definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery 
(eg, carotid surgery). 
 
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 nerve conduction studies, somatosensory study and 
electroencephalogram. Our reviewer says that CPT codes 95908 and 95927 do not meet criteria for billing or 
reimbursement consideration. The technical report does not include documentation nerve conduction studies 
have been performed. The technical report does not include documentation of peripheral nerve stimulation in 
trunk or head. Our reviewer found CPT code 95955 does not meet criteria for billing or reimbursement 
consideration. The technical report was performed throughout procedure. There is a more appropriate 
HCPCS/CPT code to report for this service.  Any additional electroencephalogram performed during procedure 
would be inclusive to the correct procedure code. 
 
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 nerve conduction studies, somatosensory study and electroencephalogram 
have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies 
(95908), short-latency somatosensory evoked potential study (95927) and electroencephalogram (95955) 
provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildups, including any pins when required (D2950) 
on tooth #'s 21 and 27 provided on April 16, 2021. 
 
You asked the Plan to pay for the core buildups. You say that you were not aware that the Plan only covered 
this service once every five years. You also say that you know you have $16.32 on the account and would like 
that to be used to cover the balance. The Plan denied your request. The Plan says these services exceed the 
maximum allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup, including any pins when 
required (D2950) is limited to one procedure per tooth every five plan years.   
The record shows that you received core buildups, including any pins when required (D2950) on tooth #'s 21 
and 27 on June 12, 2020 and your core buildup benefit for tooth #'s 21 and 27 has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the core buildups, including any pins when required (D2950) 
on tooth #'s 21 and 27 provided on April 16, 2021.