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

 
We decided that the Plan does not have to waive the coinsurance for electrical pump on April 01, 2022. 
 
You asked the Plan to waive the coinsurance for electrical pump. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare-covered durable medical equipment.  
 
The enrollee has been asked to pay a 20% coinsurance for electrical pump. Electrical pumps fall within the 
Durable medical equipment (DME) and related supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for electrical pump on April 01, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (80048, 85025, 96374, 96375, 99284, 
J1200, J2405, 93005) provided on March 24, 2022. 
 
You asked the Plan to pay for outpatient services. You say that the diagnoses billed on this claim are accurate 
and supported in the medical records. The Plan denied your request. The Plan says the diagnosis listed is not an 
appropriate principal diagnosis per Medicare regulations. Therefore, this claim is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that an outpatient claim submitted with a principal 
diagnosis code which is on the list of unacceptable principal diagnosis codes as defined by the Medicare Code 
Editor (MCE) and which is not on the exclusions list returns OCE 113. Claims which return this edit are denied 
in full and returned to the provider for correction.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, this claim was submitted with ICD-10 code 
T38.0X5A listed as the principal diagnosis. This diagnosis is on the MCE Unacceptable Principal Diagnosis 
Codes list. In addition, T38.0X5A is not on the OPPS exclusions to the Unacceptable Principal Diagnosis list. 
This means that edit 113 applies and the claim is denied and returned to the provider for correction. Therefore, 
we decided that the Plan does not have to pay for outpatient services (80048, 85025, 96374, 96375, 99284, 
J1200, J2405, 93005) provided on March 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsurgery (procedure code 69990) provided to the 
enrollee on December 9, 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 the records do 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 69990 is "microsurgical technique requiring use of 
operating a microscope (Listed separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
describe CPT 69990 as a separate procedure. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for microsurgery (procedure code 69990) provided to the enrollee on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the emergency care, CT scan, and 
outpatient rehabilitation services provided from April 15, 2022, to April 17, 2022. 
 
You asked the Plan to pay an additional amount for the hospital services. You say that the claims denied for not 
meeting the Medicare requirements. You also say that you cannot afford to pay $23,000 for the hospital stay as 
well as testing. The Plan denied your request. The Plan says that corrected claims had been submitted to them. 
The Plan also says that they were reprocessed and paid correctly. 
 
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 $120 
copayment for Emergency Care, a $250 copayment for Advanced Imaging Services, and a $35 copayment for 
Outpatient Rehabilitation Services.  
 
You have been asked to pay a $120 copayment, a $250 copayment, a $35 copayment for the hospital services. 
The hospital services fall within the Emergency Care, Advanced Imaging Services, and Outpatient Rehabilitation Services benefit categories, respectively. 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 pay an additional amount 
for the emergency care, CT scan, and outpatient rehabilitation services provided from April 15, 2022, to April 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on February 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a prosthetic provided on April 14, 2022. 
 
You asked the Plan to waive the coinsurance for a prosthetic. You say that you already paid a copayment for a 
specialist for this appointment and should not have to pay anything else. The Plan denied your request. The 
Plan says the coinsurance applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for prosthetic device and related supplies. The allowed amount of this prosthetic is $53.24 
resulting in a coinsurance amount of $10.64 ($53.24 x 20% = $10.64). 
 
You have been asked to pay a $10.64 coinsurance for a prosthetic. A prosthetic fall within the Prosthetic 
Device and Related 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 coinsurance for a prosthetic 
provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you have provided medical records with the appeal 
and would like the claim reprocessed. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 an office visit provided on January 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1832) provided March 28, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or a delivery ticket to indicate the specific 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 knee orthosis 
(L1832) provided March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 17, 2021, 
to April 23, 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 submitted records do not support the billed DRG. 
 
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.   
 
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 these services. Our reviewer says that the 
submitted records do not support the billed DRG. Our physician reviewer found the enrollee was admitted to 
the hospital with altered mental status and new onset seizure. On admission he was unresponsive, did not 
follow commands, and was on minimal ventilator support. He was stable for discharge with home health for 
suctioning. The submitted records do not support the billed DRG.  
 
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 the inpatient hospital services rendered from April 17, 2021, to April 23, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for synovectomy provided to the enrollee on November 2, 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 records do 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 26145 is "Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, 
each tendon." 
 
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 supported by the medical records. Our reviewer found that the operative note cites the median 
nerve and flexor tendons were encased in thick matting scar tissue adhesions and tenosynovium. Using scissors 
and pickups, the carpal tunnel flexor tendons and median nerve were carefully dissected free of scar tissue and 
tenosynovium. Therefore, the records do support that 26145- synovectomy, tendon sheath, radical 
(tenosynovectomy), flexor tendon, palm and/or finger, each tendon- 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 
synovectomy provided to the enrollee on November 2, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service September 
11, 2021. 
 
You asked the Plan to pay for procedure code 93010. You say that a provider who prepares a separately 
identifiable interpretation which contributes to the diagnosis of the patient is entitled to payment. You say that 
the denied service should be reprocessed. The Plan denied your request. The Plan says payment for code 93010 
is bundled into payment for code 36556.  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 93010 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service September 11, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210 x 2) and the placement of an intra-socket biological dressing to aid in the 
hemostasis or clot stabilization, per site (D7922 x 2) provided on July 13, 2021. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
enrollees contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2) and the placement of an 
intra-socket biological dressing to aid in the hemostasis or clot stabilization, per site (D7922 x 2) provided on 
July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adiiton, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845), addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848), addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856), all lower extremity 
prostheses, flex-walk system or equal (L5981) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not appear to function at a K3 level. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The documentation 
indicates that the requested item has features that exceed the patient's medical need and the documentation is 
conflicting that the patient requires the C-leg 4. The patient's activities do not appear to be a K3 level. 
Additionally, there are no extenuating factors on the medical progress notes that require a microprocessor knee.   
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an adiiton, endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), addition to endoskeletal 
knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), addition to 
lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase, includes electronic sensor(s), any type (L5856), all lower extremity prostheses, flex-walk system or 
equal (L5981) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supply allowance (K0553) 
provided on February 13, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says that this claim has not bee billed as 
required by Medicare coding regulations. 
 
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. In this case, the Plans denial hinges on a claim that was previously paid for the 
CGM supply allowance on January 30, 2022. However, a copy of this claim was not provided in the record 
submitted. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) supply 
allowance (K0553) provided on February 13, 2022.  
 
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 initial nursing facility care, and wound debridement provided 
on January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial nursing facility care and wound debridement. You say that due to the place 
of service settings, it is not always possible to obtain an authorization for every visit prior  to the provider 
rendering the services. The Plan denied your request. The Plan says a review confirmed that there was no prior 
authorization submitted to the Plan to request coverage for out-of-network care with skilled nursing facility 
wound care service. The Plan also says that the member was in a skilled nursing facility stay that was not 
covered by them. 
 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 initial nursing facility care, and wound 
debridement provided on January 20, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on 
January 14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided on January 14, 2022.