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

 
We decided that the Plan has to pay for procedure code 96361. We decided that the Plan does not have to pay 
for procedure code J7030.  
 
You asked the Plan to pay for the intravenous (IV) hydration services billed with codes 96361 and J7030 
rendered on July 5, 2022. You say that you disagree with the denial. The Plan says that the services are not 
separately payable. 
 
We decided that the Plan has to pay for procedure code 96361.  
 
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 states that procedure code 96361 has an OPPS status indicator of S and 
is not payable. While the code does have an OPPS status indicator of S, this status indicator does not signify 
that the code is not payable. This status indicator states that it is paid under OPPS with separate ambulatory 
payment classification (APC) payment. The Plan has not provided any documentation or Medicare rules to 
support that the code is not payable as billed. Therefore, we decided that the Plan has to pay for procedure code 
96361 billed on July 5, 2022.  
 
We also decided that the Plan does not have to pay for procedure code J7030. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 96361 has an OPPS status indicator of N and 
not separately payable. Therefore, we decided that the Plan does not have to pay for procedure code J7030 
billed on July 5, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray (73564) provided on February 22, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the service was necessary. The Plan denied your request. 
The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. 
The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the knee x-ray (73564) provided on February 22, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical knee arthroscopy (procedure code 29876) provided to the 
enrollee on June 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied code cannot be verified. 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure description cites a 
medial synovectomy was done, there was synovitis in the intercondylar notch and a synovectomy was done, 
and the lateral compartment revealed synovitis anteriorly, and a synovectomy was done. Therefore, the records 
do support that CPT 29876: arthroscopy, knee, surgical, synovectomy, major 2 or more compartments (e.g., 
medial or lateral) was rendered in this case. The enrollee was being treated for other synovitis and 
tenosynovitis right lower leg; chondromalacia patellae of the right knee; complex tear of the medial meniscus 
of the right knee; and other specified arthritis of the right knee.  He underwent an arthroscopic 
multicompartment synovectomy and partial medial meniscectomy and chondroplasty on 6/7/22.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical knee arthroscopy (procedure code 29876) provided to the enrollee on June 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82570 and 83986 billed for services 
provided on May 3, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes cannot 
be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We find that the testing described by the billed codes are considered specimen validity testing which is not 
separately payable. 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 procedure codes 82570 and 83986 billed for 
services provided on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88342, 88323, 88341, 88365) provided 
on February 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 laboratory services (88342, 88323, 88341, 88365) 
provided on February 11, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) provided on May 6, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that this should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) provided on May 6, 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 would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and you can safely receive the services you need in the current hospital setting. 
 
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 you are medically stable and do not require close supervision for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you can benefit from 
physical and occupational therapy, your needs can be safely provided in an alternate level of care such as a 
skilled nursing facility. 
 
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 pay for procedure code 99053 billed for date of service April 3, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99053 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 24, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the facility requested your 
services and typically they handle any authorizations, if needed, and the services would fall under the facility 
authorization. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
 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 subsequent nursing facility care provided on June 
24, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care office visit provided on June 2, 
2022. 
 
You asked the Plan to waive the copayment for urgent care office visit. You say that you are appealing for a 
reduction in copayment from $30 to $15 for an urgent care office visit. 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 $30 
copayment for urgently needed services.  
 
You have been asked to pay $30 copayment for urgent care office visit. This item/service falls within the 
urgently needed 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 urgent care 
office visit provided on June 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0998) provided 
on June 17, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your sister called the 
ambulance because you were having a dizzy spell. You also say that once the ambulance arrived, they checked 
your vitals, and your sister ended up taking you to the emergency room, instead of the ambulance. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The rules also 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 $275 copayment for Ambulance services.  
 
Although ambulance response and treatment with no transport (A0998) is not covered by Medicare, you have 
been asked to pay a $275 copayment for the ambulance services. This item/service 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 the ambulance services 
(A0998) provided on June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right heart catheterization including measurement(s) 
of oxygen saturation and cardiac output, when performed (93451). 
 
You asked the Plan to pre-approve a right heart catheterization. You say that the enrollee is a congestive heart 
failure NYHA class 3 and needs this procedure. The Plan denied your request. The Plan says the request for 
right heart catheterization does not meet the Medicare requirements for reasonable and necessary. The medical 
record does not support the need for further right heart evaluation or the medical necessity for placement of an 
LVAD given that your condition is currently well controlled with medical management without evidence of 
poor perfusion. 
 
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 a right heart catheterization. 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 a cardiac catheterization with PCI in 2021. Another 
physician, who is evaluating the enrollee for possible LVAD after the CRT-D implant, has requested 
authorization for RHC. Documentation does not support the rationale for this invasive imaging study prior to 
CRT-D implant. Guidelines do not support a need for RHC in this setting. As a result, at this time RHC would 
not be considered medically appropriate and necessary in this enrollee's 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 a right heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right heart catheterization including measurement(s) of oxygen saturation 
and cardiac output, when performed (93451).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vagifem. 
 
You asked the Plan to pre-approve Vagifem. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vagifem.  
 
Benefits for Vagifem may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on February 14, 2022. 
 
You asked the Plan to pay for the physician service. You say that the claim should be reprocessed and paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the rest home visit (99336) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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. Outpatient diagnostic testing 
requires prior authorization. The Plan did not pre-approve the services at issue. We found no exception that 
would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on May 16, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you disagree with the coinsurance. 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for an injection. The total allowed amount for the injection 
$29,397.50 ($29,397.50 x 20% = $5,879.50). However, you are only being asked to pay $2,595.74 which is 
less than the required amount. 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 an injection provided on 
May 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on May 25, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you do not think you should 
be charged $275.00.  You also say that you would like the Plan to pay more as you are on a limited income. 
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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for ambulance transport. This item/service 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 May 25, 2022.