Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for dates of service January 15, 
2021, to April 7, 2021. 
 
You asked the Plan to pay for procedure code 99072. You say that this service was coded correctly. The Plan 
denied your request. The Plan says no separate payment is made for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99072 billed for dates of service January 15, 2021, to April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says that, at the time of their review, they did not 
receive medical records to show that the criteria for coverage have been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 14-day sensor. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has type 
two diabetes and varies doses of Novolog at meals according to blood glucose levels. The enrollee takes 4 shots 
of insulin per day and adjusts according to blood glucose levels at meals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre 14-day sensor have been met. Therefore, we decided that the 
Plan has to pre-approve a Freestyle Libre 14-day sensor.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 17, 
2021, to July 16, 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 claim was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The provider did not send in a Request for Anticipated Payment (RAP) for this claim. 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 home health services provided to the enrollee from June 17, 
2021, to July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 19, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on October 19, 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 your doctors have recommended the rehabilitation. 
The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting 
have not been met. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Our physician reviewer 
also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated scooter. 
 
You asked the Plan to pre-approve a power operated scooter. You say that you have difficulty walking. You 
also say that you would like this item to attend office visits and getting around outside of the home. The Plan 
denied your request. The Plan says the requested item is not a covered benefit for outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from December 28, 2021, to 
January 1, 2022. 
 
You asked the Plan to pay for inpatient care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and the enrollee was stable enough to be transferred to an in-network facility for 
treatment. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that this 
inpatient stay does not meet criteria for payment. Our physician reviewer found the enrollee presented to the 
emergency department on December 28, 2021 with chest pain and hemoptysis and was noted to have a cavitary 
lung lesion concerning for aspergillosis. The enrollee was evaluated and started on voriconazole. The review 
indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with 
monitoring to a Plan network facility. There is no documentation provided indicating the medical necessity for 
post-stabilization care services at an out-of-network facility. The treating physician did not note that the 
enrollee was not stable for transfer on any date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital care provided from December 28, 2021, to January 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on March 9, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for an ultrasound.  
 
You have been asked to pay a $50 copayment for an ultrasound. An ultrasound falls 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 copayment for an ultrasound on March 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
30, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you don't think you should 
have to pay more than the insurance company does. You don't believe you should have to pay this much. The 
Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $295 
copayment for each Medicare-covered one-way trip via ground ambulance. 
 
You have been asked to pay $295 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance services 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 ambulance transport 
provided on December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ECG provided on January 19, 2022. 
 
You asked the Plan to waive the copayment for ECG. You say that you were told this procedure would be 
covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $180 
copayment for each Medicare-covered special imaging procedure and special diagnostic test.  
 
You have been asked to pay $31.82 which is less than the standard $180 copayment for ECG. ECGs 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 copayment for ECG provided on January 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 27, 2022. 
 
You asked the Plan to pay for the ambulance transportation and ground mileage. You say that you would like 
this claim to be reprocessed for payment. The Plan denied your request. The Plan says this service is not 
covered. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 ambulance transportation and ground 
mileage. Our reviewer says that the documentation does not support that the ambulance transport on January 
27, 2022 was medically reasonable and necessary for the patient. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this patient. The patient was transported by 
stretcher after discharge from a hospital to a memory care facility. Our reviewer found that a stretcher van 
would have been an appropriate means of transport. The documentation does not support that the patient 
needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance could provide for safe transport on January 27, 2022. Our physician reviewer also found that the 
patient was stable and there was no documented need for basic life support or advanced life support monitoring 
or 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 the ambulance transportation and ground mileage have not been met. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive your coinsurance for LifeVest provided from October 26, 
2021, to December 26, 2021. 
 
You asked the Plan to waive your coinsurance for a LifeVest. You say that you should not have to pay your 
coinsurance because you were not able to use the vest accurately as instructed by your doctor. The Plan denied 
your request. The Plan says you must pay a 20% coinsurance for durable medical equipment. 
 
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 Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay a 20% coinsurance for a Lifevest. A Lifevest falls within the Durable Medical 
Equipment (DME) 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 your 
coinsurance for an automated external defibrillator garment (LifeVest) from October 26, 2021, to December 
26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88104, 88305, 88312, 88361) 
provided on September 16, 2021. 
 
You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services have not been billed with an 
appropriate modifier as required for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that only the hospital may 
bill for the technical 
component (TC) of a physician pathology service provided to an inpatient or outpatient.  
We looked at the file and Medicare rules. The records indicate that the enrollee was a hospital patient at the 
time of service, and this service was not billed with a modifier to indicate only the professional component is 
being billed. Based on this information, we decided that Medicare rules for coverage of the pathology services 
have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services (88104, 
88305, 88312, 88361) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from September 14, 2021, to 
November 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received from September 14, 2021, to November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology (prostate) gene expression profile (0005U). 
 
You asked the Plan to pre-approve an oncology (prostate) gene expression profile. The Plan denied your 
request. The Plan says this request is not medically necessary. 
 
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 an oncology (prostate) gene expression 
profile. Our reviewer says that an oncology (prostate) gene expression profile is not considered medically 
reasonable and necessary in this case. Our physician reviewer found your request is not medically necessary 
because your prostate-specific antigen (PSA) test is higher than 10 and you have had an initial biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oncology (prostate) gene expression profile have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an oncology (prostate) gene expression profile (0005U).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression stockings identified with 
code A6530 that were purchased on February 9, 2022. 
 
You asked the Plan to issue reimbursement for the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a 
covered benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to issue reimbursement for the 
compression stockings identified with code A6530 that were purchased on February 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on August 5, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, we have confirmed that code J2001 is a 
column II code to column I code 20611. This claim has not been billed with an appropriate modifier to bypass 
the edit.  
 
We find that CPT code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S0020 is not valid for Medicare purposes. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for the pain management services 
provided on August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bench. 
 
You asked the Plan to pre-approve a bench. You say that you would like this item to help you get on the bed. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bench.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for anesthesia for lens surgery provided on 
January 26, 2022, and February 9, 2022. 
 
You asked the Plan to waive the coinsurance for anesthesia for lens surgery. You say that you were told the 
provider was in network so you shouldn't have to pay this much. The Plan denied your request. The Plan says 
the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 30% 
coinsurance for out-of-network surgery services provided at outpatient hospital or ambulatory surgical center. 
 
 
 
 
 You have been asked to pay $37.30 total which is 30% of the allowed amount for the anesthesia for lens 
surgery. Anesthesia for lens surgery falls within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for anesthesia for lens surgery provided on January 26, 2022, and February 9, 2022.