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

 
We decided that the Plan has to pay for the medical services provided on August 4, 2022, billed with codes 
J3490 and 77003. 
 
You asked the Plan to pay for the medical services. You say that this was billed correctly and should be paid. 
The Plan denied your request. The Plan says that the billed items are included in payment for other services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not performed a full appeal review of the denial at issue. The Plan 
did not offer a specific rationale to support that the services in this case were denied correctly. As such, the 
denial is not substantiated. Therefore, we decided that the Plan has to pay for the medical services provided on 
August 4, 2022, billed with codes J3490 and 77003.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diagnostic colonoscopy and 
esophagogastroduodenoscopy provided on November 9, 2022. 
 
You asked the Plan to waive the cost share for the colonoscopy and esophagogastroduodenoscopy. You say 
that you have never received a bill for a preventative service before. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan 
also says that there is 30% coinsurance after the deductible has been met for outpatient procedures and 
services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed 
in an outpatient hospital.  
 You have been asked to pay $706.21, which satisfies the remainder of your deductible. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to out-of-
network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers. This cost sharing is a contractual obligation that had not been met at the time the diagnostic 
colonoscopy and esophagogastroduodenoscopy was received on November 9, 2022. 
 
The remaining allowed amount after the deductible was satisfied is $536.57 ($1,242.78 allowed amount - 
$706.21 = $536.57). You have also been asked to pay $160.97, which is 30% coinsurance of the allowed 
amount for the outpatient surgeries ($536.57 remaining allowed amount x 30% coinsurance = $160.97). You 
have been asked to pay a total of $867.18 ($706.21 deductible + $160.97 coinsurance = $867.18). These items 
or services you asked the Plan to waive the cost share for 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 cost share for the diagnostic colonoscopy and esophagogastroduodenoscopy 
provided on November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan does not 
have to pre-approve SSBCI benefits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 27, 2021, 
through April 30, 2021, and billed with diagnosis code J96.01. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.01 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.01. 
 
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 secondary diagnosis code J96.01-acute respiratory 
failure with hypoxia. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of J96.01 acute respiratory failure with hypoxia. Our physician reviewer found the member was 
placed on a non-rebreather and given an albuterol treatment in route with improvement in symptoms. The 
member's vital signs in the emergency department noted that the member had a respiratory rate of 18 and a 
oxygen level of 93% on 2 litters of nasal cannula. The member's supplemental oxygen was increased to a 
maximum of 4 litters in the emergency department, and the history and physical noted that at the time of the 
assessment, the member was on 3 litters via nasal cannula. The member was discharged home requiring 1 litter 
via nasal cannula. There was no clinical or laboratory evidence of acute respiratory failure with hypoxia. 
Therefore, secondary diagnosis code J96.01-acute respiratory failure with hypoxia is not the appropriate 
secondary diagnosis.  
 
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 on April 27, 2021, through April 30, 2021, and billed with diagnosis 
code J96.01.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) home physical therapy (PT) visits. 
 
You asked the Plan to pre-approve twelve (12) home physical therapy (PT) visits. You say that twelve (12) 
home physical therapy (PT) visits are medically necessary. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 twelve (12) home physical therapy (PT) 
visits. Our reviewer says that the requested twelve (12) home physical therapy (PT) visits are not medically 
reasonable and necessary. Our physician reviewer found that the enrollee is an 86-year-old who began 
receiving home health therapy services beginning November 7, 2022, status post low blood pressure, kidney 
disease, and a bladder infection. The enrollee has been instructed on safety measures, an emergency plan, fall 
precautions, etc. Ample time has been provided to establish a home exercise program. The prior level of 
function is documented as independent. The physical therapy note from March 16, 2023, documents no recent 
hospitalizations. The functional assessment documents that the enrollee is ambulating 310 feet with a rolling 
walker and stand by assistance. The enrollee is independent for bed mobility. There is no documentation of a 
recent face-to-face visit with the enrollee's provider.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of twelve (12) home physical therapy (PT) visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve twelve (12) home physical therapy (PT) visits.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration because 
the requested incontinence supplies are medically necessary. The Plan denied your request. The Plan says the 
requested incontinence supplies are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasound scan of the abdominal aorta (76706) provided on 
September 09, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the claim was not billed with the appropriate diagnosis codes. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the ultrasound by a contract provider. The file does not show that the plan 
provided notice that the ultrasound would not be covered. Under Medicare rules, this means the ultrasound is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for an ultrasound scan of the 
abdominal aorta (76706) provided on September 09, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI scan of blood vessels of head without contrast 
(70544) provided on September 14, 2022. 
 
You asked the Plan to pay for an MRI. You say that the claim should be paid as billed. The Plan denied your 
request. The Plan says current procedural terminology (CPT) code (70544) is inherent to CPT 70553. 
 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 70544 is a column II code to column I code 70553; however, 70544 
was billed with a modifier.  
 
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 an MRI. Our reviewer says that the provider reported, current 
procedural terminology (CPT) 70544-Magnetic resonance angiography, head; without contrast material(s) in 
addition to Magnetic resonance (eg, proton) imaging, brain (including brain stem) for the same date of service.  
Our reviewer found that the procedure report does not provide clear documentation to support the MRI scan of 
blood vessels of head without contrast billed was provided.  
 
In terms of CPT 70544, the medical record does not support clear documentation that there were two separate 
technical exams. Not one set of images that was interpreted as an MRI and then reformatted for MRA. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pay for an MRI scan of blood vessels of head without contrast (70544) provided on September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder (ILR). You say that the medical records 
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the 
records do not support that this request meets the medically necessary criteria for ILR placement. 
 
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 the implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any 
significant cardiac arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that 
continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on August 29, 2022, billed with codes 
J3490 and 99213. 
 
You asked the Plan to pay for the medical services at issue. You say that this was billed correctly and should be 
paid. The Plan denied your request. The Plan says that the billed items are included in payment for other 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not performed a full appeal review of the denial at issue. The Plan 
did not offer a specific rationale to support that the services in this case were denied correctly. As such, the 
denial is not substantiated. Therefore, we decided that the Plan has to pay for the medical services provided on 
August 29, 2022, billed with codes J3490 and 99213.  
 
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 waive the copayment for the specialist office visit provided on 
October 31, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this should be 
considered a follow-up appointment and should be covered. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $45 
copayment per visit for an in-network specialist office visit. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls 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 copayment for the specialist office visit provided on October 31, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes 72131 and 72192. We decided that the Plan does not have to pay 
for codes 96367, 96374, and 93005.  
 
You asked the Plan to pay for imaging services described by codes 72131 and 72192 and the other medical 
services described by codes 96367, 96374, and 93005 provided on September 27, 2022. You say that the claim 
was billed correctly and should be paid. The Plan says that the place of service is inappropriate for the service 
billed. 
 
We decided that the Plan has to pay for codes 72131 and 72192.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for codes 72131 and 72192.  
 
We also decided that the Plan does not have to pay for codes 96367, 96374, and 93005. 
 
The rules say that A/B Medicare Administrative Contractors (MACs) (B) may not pay for the technical 
component (TC) of radiology services furnished to hospital patients.  
 
We find that the Professional Component/Technical Component (PC/TC) indicator for codes 96367 and 96374 
is 5, which means these services cannot be paid in the facility setting. Therefore, we decided that the Plan does 
not have to pay for codes 96367 and 96374. We find that the PC/TC indicator of code 93005 is 3, which means 
its a code that is TC only. Since this is a professional claim in a facility setting, the TC is not payable to the 
physician in that setting. Therefore, we decided does not have to pay for the services described by codes 96367, 
9634, and 93005. 
 
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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the dialysis treatment provided from May 1, 2022, 
to May 31, 2022. We also decided that the Plan does not have to fully wave the coinsurance for the dialysis 
treatment provided from May 1, 2022, to May 31, 2022. 
 You asked the Plan to waive the coinsurance for the dialysis treatment. You say that you should not have been 
put on dialysis. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. Your contract with the Plan says that enrollees must pay 20% coinsurance out-of-
network services to treat kidney disease. 
 
We decided that the Plan has to reduce the coinsurance for the dialysis treatment provided from May 1, 
2022, to May 31, 2022.  
 
The Plan says you must pay $61.98 for the dialysis treatment. Based on the Plan contract, however, you cannot 
be asked to pay more than 20% coinsurance of the allowed amount, the correct amount you owe is $61.49 for 
the dialysis treatment ($307.43 allowed amount x 20% coinsurance = $61.49). Therefore, we decided that the 
Plan has to reduce the coinsurance for the dialysis treatment provided from May 1, 2022, to May 31, 2022. 
 
We also decided that the Plan does not have to fully waive the coinsurance for the dialysis treatment 
dialysis treatment provided from May 1, 2022, to May 31, 2022. 
 
Dialysis treatment falls within the services to treat kidney disease 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 fully waive the coinsurance for the dialysis treatment dialysis treatment provided from May 1, 2022, to May 
31, 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.