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

 
We decided that the Plan has to pay for the critical care services (99291-25 and 99292-25) provided on 
September 14, 2021. 
 
You asked the Plan to pay for codes 99291-25 and 99292-25. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make 
a determination within the allotted time frame. 
 
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. The definition of code 99292 is Critical care, evaluation and management of the critically ill or 
critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 
 
We find that CPT codes 99291-25 and 99292-25 are supported in the medical record. Specifically, the records 
document that critical care time was provided to the enrollee on September 14, 2021, the same day as the 
intubation procedure (31500) and provided by the same provider. Based on this information, we decided that 
Medicare rules for coverage of codes 99291-25 and 99292-25 have been met. Therefore, we decided that the 
Plan has to pay for the critical care services (99291-25 and 99292-25) provided on September 14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 5, 2021. 
 
You asked the Plan to pay for the testing services. You say that good faith services were rendered to the 
enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 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 the rules. We find that the testing is not supported. The file does not contain an order 
or medical records. There is no documentation to show what was ordered and the reasoning for the testing. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on November 30, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing is a covered service. The Plan 
denied your request. The Plan says medical records were not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the carrier sufficient 
information to determine whether payment is due. 
 
 We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
testing was reasonable and necessary. The file shows that the Plan made multiple attempts to obtain records 
without success. Therefore, we decided that the Plan does not have to pay for the lab testing services provided 
on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation and treatment with an out of network 
(OON) provider. 
 You asked the Plan to pre-approve consultation and treatment with an OON provider. You say that there are no 
in network providers who can perform the surgery needed. You say that the Plan tried to send you to a surgeon 
that was not familiar with your condition. You say that you need to see the requested OON provider, who 
specializes in your condition, before you can schedule the needed surgery. You say that the requested OON 
provider is better qualified to perform the parathyroid surgery than a general surgeon. The Plan denied your 
request. The Plan says there are network providers within a reasonable distance of the enrollee's location that 
can provide the needed care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 consultation and treatment with an 
OON provider. Our reviewer says that the criteria for coverage of OON care have been met. Our physician 
reviewer found the enrollee has primary hyperparathyroidism. The Plan is medically justified on the basis that 
it is offering adequate care to meet the enrollee's medical needs through referral to their network providers. 
There is nothing unique about the enrollee's condition that would make it medically necessary to see the 
requested OON provider. The Plan has shown that they have network providers who meet the Standards of 
Care required for treatment of the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of consultation and treatment with an OON provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve consultation and treatment with an out of network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 8, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician office visit (99204), provided on June 16, 
2021. 
 
You asked the Plan to pay for the physician office visit. You say that the service should be covered. The Plan 
denied your request. The Plan says a valid EOB was not received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the physician office visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the physician office visit (99204), provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hospital discharge day management (99239) provided on 
June 6, 2021. 
 
You asked the Plan to pay for code 99239. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, code 99239 is a time-based 
code. In order to bill CPT 99239, the documentation must note that more than thirty minutes was spent 
providing services to the enrollee on the day of discharge. The progress note for June 6, 2021 does not note 
how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99239. Based on this information, we decided that Medicare rules for coverage of 
code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for the Hospital 
discharge day management (99239) provided on June 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 13, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient care provided on April 14, 2021. 
 
You asked the Plan to pay for evaluation and management service. You say that the medically necessary 
services were rendered to the enrollee at the request of the facility. The Plan denied your request. The Plan says 
that the claim denied correctly. 
 
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 initial request and denial were requested but not received. 
Therefore, we decided that the Plan has to pay for the outpatient care provided on April 14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 15, 2021. 
 
You asked the Plan to pay for the testing services. You say that drug testing is needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says the test cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We find that CPT code 83789 was billed for specimen validity testing. validity testing on urine specimens used 
for drug testing shall not be billed separately. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing provided on October 18, 
2021. 
 
You asked the Plan to pay for the testing services. You say that the medical records support the billed charges. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the rules. The panel testing at issue was billed with multiple codes. If a single 
procedure is performed, only one code with one unit of service may be reported for the procedure. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenomics testing provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyewear provided on December 15, 2020. 
 
You asked the Plan to pay more for the eyewear. The Plan denied your request. The Plan says the claim was 
processed correctly. 
  The Plan must follow Medicare rules. The rules say that Medicare only covers standard frames and lenses for 
glasses after cataract surgery.  
 
We looked at the file, and the Plan's rules. The Plan is only responsible to reimburse for covered services based 
on the allowed amount of the service. The eyewear that was denied are considered upgrades and are not 
covered. This means that the claim processed correctly. Based on this information, we decided that the Plan's 
rules for additional coverage of the eyewear have not been met. Therefore, we decided that the Plan does not 
have to pay more for the eyewear provided on December 15, 2020.
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 May 
9, 2020, to May 12, 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 the provider did not bill as required by Medicare coding regulations.  
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 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 there is no documentation of persistent hypotension or hemodynamic 
instability. There is no evidence of significant physiologic instability. DRG 690: KIDNEY AND URINARY 
TRACT INFECTIONS WITHOUT MCC is more appropriate in this case.  
 
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 May 9, 2020, to May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
August 11, 2021, to September 9, 2021.  
You asked the Plan to pay for home health services. You say that this was medically necessary. The Plan 
denied your request. The Plan says the payment was adjusted on the final bill. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, The deadline 
for submission of the RAP claim is within 5 days of the start of care. The RAP claim was submitted by the 
provider on September 17, 2021.. Therefore, we decided that the Plan does not have to pay for the home health 
services provided to the enrollee from August 11, 2021, to September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization (37224), angiography (75710), and 
introduction of needle or intracatheter (36140), provided on September 13, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the revascularization, angiography, and introduction of needle or intracatheter. 
You say that the service was medically necessary. The Plan denied your request. The Plan says the services 
were obtained by an out-of-network provider. 
 
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 the revascularization (37224), angiography 
(75710), and introduction of needle or intracatheter (36140), provided on September 13, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses and fitting of contact lens provided on 
November 3, 2021. 
 
You asked the Plan to pay for contact lenses and fitting of contact lens. You say that the Plan vision benefit is 
insufficient for your needs. The Plan denied your request. The Plan says you received the vision benefit on 
July 15, 2020, and are responsible for the charges on this claim. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years. 
 
We looked at the file and the Plan's rules. The file shows that you received the vision benefit on 
July 15, 2020, and you have reached the maximum vision allowance and you are responsible for the charges on 
this claim. Therefore, we decided that the Plan does not have to pay for contact lenses and fitting of contact 
lens provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530), provided on August 18, 
2021, and August 20, 2021. 
 
You asked the Plan to pay for the therapeutic activities. You say that the service should be covered. The Plan 
denied your request. The Plan says an inappropriate code was used for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic activities have not been met. Specifically, the record shows that this claim was 
billed by a Nurse Practitioner. The record also shows that these services were provided by an OTA. It is not 
appropriate to bill the services of an OTA as services incident to a Nurse Practitioner because the Nurse 
Practitioner does not meet the qualifications of a therapist. Therefore, we decided that the Plan does not have to 
pay for the therapeutic activities (97530), provided on August 18, 2021, and August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyewear upgrades provided by on 
January 15, 2021. 
 
You asked the Plan to pay an additional amount for the eyewear upgrades. The Plan denied your request. The 
Plan says the 2021 Evidence of Coverage benefit specifies that any additional lens options or upgrades are not 
covered including, but not limited to, Deluxe, Premium or Platinum progressive lenses, blended bifocal, 
Hi Index, tinting, scratch coating, UV or anti-reflective coating, and polycarbonate are not covered. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the eyewear upgrades are not a covered vision 
benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear upgrades 
provided on January 15, 2021.