Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36245, 37242, 75710 and 76937 billed on 
January 29, 2022. 
 
You asked the Plan to pay for procedure codes 36245, 37242, 75710 and 76937. You say that the medical 
records should be reviewed, and the claim processed for payment. The Plan denied your request. The Plan says 
procedure codes 36245, 37242, 75710 and 76937 are not supported by the medical records submitted. 
 
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 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 procedure codes 36245, 37242, 75710 and 76937. Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the procedure report does not describe a vascular embolization or occlusion, a selective 
catheter placement into arterial system or angiography. The procedure report also does not include 
documentation of ultrasound guidance for vascular access. Therefore, these procedures cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36245, 37242, 75710 and 76937 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 36245, 37242, 75710 and 76937 billed on 
January 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PureWick female catheter. 
 
You asked the Plan to pre-approve the PureWick female catheter. You say that this is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says use of this system is considered experimental 
and investigational. 
 
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 the PureWick female catheter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on January 
18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not able to go home in this condition and you 
need therapy so you can return to baseline. The Plan denied your request. The Plan says the services you need 
can safely be provided in other settings. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that  The Plan 
denied your request. The Plan says there are in-network providers that are able to provide these services. 
Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services coded 11000 provided on 
September 9, 2021. 
 
You asked the Plan to pay for the debridement services coded 11000. You say that you would like this claim 
reprocessed and approved for payments. The Plan denied your request. The Plan says the billed CPT code is 
not supported in the medical records submitted. 
 
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 11000 is debridement of extensive eczematous or 
infected skin; up to 10% of body surface. 
 
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 debridement services coded 11000. Our reviewer says 
that the documentation does not support the billed CPT code 11000. Our reviewer found the operative report does not include documentation of debridement of extensive eczematous or infected skin. In this case, the 
operative report documents "Signs of infection: No objective signs of infection present at this time. Wound 
debridement: wound debridement performed this date of service. Debridement technique: Irrigation".  The 
procedure report does not include enough documentation to confirm debridement of extensive eczematous or 
infected skin was performed. 
 
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 debridement services coded 11000 have not been met. Therefore, we 
decided that the Plan does not have to pay for the debridement services coded 11000 provided on September 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the provider ordered this 
service for you, as you would not have been able to get home and back inside without help. The Plan denied 
your request. The Plan says you were charged this cost sharing 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 $295 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $295 for these 
services. 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 ambulance services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81286, 81410, 81411, 81413, 81414) provided 
September 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service as medically necessary. The Plan 
denied your request. The Plan says this service is not covered as cardiovascular disease screening. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes can be billed for 
Cardiovascular Disease Screening: 80061, 82465, 83718, & 84478.  
 
We looked at the file and Medicare rules. Genetic cardiovascular screening is not covered as Cardiovascular 
Disease screening under Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (81286, 81410, 81411, 81413, 81414) provided September 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on September 7, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that physical therapy sessions were 
the result of a car accident that was not your fault. You say that the other insurance company has accepted full 
responsibility and you would like to be reimbursed the copay. The Plan denied your request. The Plan says the 
copayment amount applied is correct. A dispute of responsibility with another insurance company can not be 
reviewed.  
 
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 
copayment for Medicare-covered physical therapy (in-person or virtual) visits. You have been asked to pay a 
$20 copayment for a physical therapy session.  A physical therapy session falls within the Outpatient Rehabilitation 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 physical therapy provided on September 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 14, 2021, to November 22, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that payment was included in the 
claim and changes may need to be made. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were in the hospital from November 14, 2021, to November 22, 2021. Therefore, you 
have been asked to pay $225 per day for days 1-5 of inpatient care. The total for your stay is $1,125 ($225 
copayment x 5 days = $1,125). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from November 14, 2021, 
to November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). You 
have bilevel positive airway pressure (BiPAP) at home but there are no data on compliance. The average 
volume-assured pressure support (AVAPS) mode can be provided via BiPAP, and Medicare does not cover a 
home ventilator when used as BiPAP.  
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee no longer needs acute services. The 
enrollee is clinically ready for pulmonary rehabilitation. The Plan denied your request. The Plan says an 
intensive rehabilitation program is not medically necessary. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for injection and office visit on April 19, 
2022. 
 
You asked the Plan to waive the copayments for injection and office visit. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B covered drugs at specialists office. These drugs are covered under Part B of 
Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
include drugs that usually aren't self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. You must pay a $50 copayment at 
specialists office. Covered services include consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of $524 and the allowed amount is $154.75. The plan paid $123.80. $154.75 
x 20% = $30.95. $50 + $30.95 = $80.95. Therefore, results in the total cost sharing amount of $80.95. 
 
You have been asked to pay a 20% coinsurance and a $50 copayment for injection and office visit. Injection 
and office visit falls within the Medicare Part B prescription drugs and Physician/Practitioner services, 
including doctor's office visits benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for injection 
and office visit on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to change the copayment for an office visit provided on May 9, 2022. 
 
You asked the Plan to change the copayment for an office visit. You say that this copayment should be for a 
prime care visit, not a specialist visit. The Plan denied your request. The Plan says the copayment 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 $40 
copayment for physician/practitioner services for a specialist.  
 
You have been asked to pay a $40 copayment for an office visit. an office visit falls within the 
Physician/Practitioner Services for a Specialist 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 change the 
copayment for an office visit provided on May 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an endoscopy with biopsy and related 
services provided on February 16, 2022. 
 
You asked the Plan to waive the cost-sharing for an endoscopy and related services. You say that you disagree 
with the charges. The Plan denied your request. The Plan says the cost-sharing applied is correct. 
 
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 $1000 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan 
also clearly says that you must pay a $195 copayment for each Medicare-covered outpatient surgery at an 
in-network ambulatory surgical center. 
 
The item or service you asked the Plan to waive the cost-sharing for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers, benefit 
category.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible and 
a $195 copayment which applies to each Medicare-covered outpatient surgery at an in-network ambulatory 
surgical center. This cost sharing is a contractual obligation that had not been met at the time an endoscopy 
with biopsy and related services was received on February 16, 2022. Therefore, we decided that the Plan does 
not have to waive the cost-sharing for an endoscopy with biopsy and related services provided on February 16, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are met. 
 
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 services are not medically necessary. Our physician reviewer found the submitted records do not document 
a medically-accepted indication for which a dose of Botox at every 10 weeks, as opposed to the standard dose 
of every 12 weeks. The records and Medicare-approved drug compendia do not support the use of Botox 
injections at every 10 weeks. The services are therefore not reasonable or medically necessary. 
 
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 Botox.