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

 
We decided that the Plan does not have to waive the coinsurance for ferric derisomaltose injections provided on 
December 7, 2021. 
 
You asked the Plan to waive the coinsurance for ferric derisomaltose injections. You say that if you had any 
idea how much this infusion would cost, you would never have had it done.  You say that you are on a limited 
income and did what the doctor recommended. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $497.40, which is 20% of the allowed amount for the ferric derisomaltose 
injections. The allowed amount is $2,487 (20% x $2,487 = $497.40). Ferric derisomaltose injections fall within 
the Medicare Part B prescription drugs 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 ferric derisomaltose injections provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on November 16, 2021, and 
November 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that both Initial Hospital Care (CPT codes 99221 - 
99223) and Subsequent Hospital Care codes are "per diem" services and may be reported only once per day by 
the same physician or physicians of the same specialty from the same group practice.  
 
We looked at the file and Medicare rules. The services in question were reported with another evaluation and 
management code (99232) on same dates of service, by a provider of the same specialty and in the same group 
practice. As code 99232 has been paid, code 99233 is not separately payable. 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 the services (99233) provided on November 16, 2021, and November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living facility visit provided on October 22, 
2021, by an OON provider. 
 
You asked the Plan to pay for the assisted living facility visit. You say that the assisted living facility is 
responsible for obtaining prior authorization. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 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 assisted living facility visit provided on 
October 22, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision care services (92004, 92083, 
92250, 76514) provided on August 25, 2021. 
 
You asked the Plan to waive the copayment for vision care. You say that you expected this to be a specialist 
copayment of $45 like it was when you saw this provider earlier in the year. The Plan denied your request. The 
Plan says this claim was processed correctly, and your copayment was assessed in accordance with your 
contract. 
 
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 services for the diagnosis and treatment of diseases and injuries of the eye.  
 You have been asked to pay a $50 copayment for vision care. Vision care falls within the services for the 
diagnosis and treatment of diseases and injuries of the eye 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 vision care services (92004, 92083, 92250, 76514) provided on August 25, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71250) provided on December 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71250 
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 services (71250) provided on December 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of substance into middle or upper spine 
canal using imaging guidance. 
 
You asked the Plan to pre-approve an injection of substance into middle or upper spine canal using imaging 
guidance. 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 follows Medicare rules. Medicare rules say that epidural steroid injections are 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 an injection of substance into middle or 
upper spine canal using imaging guidance. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the spine injection is not medically needed and is dangerous as this enrollee has 
spinal cancer. 
 
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 injection of substance into middle or upper spine canal using imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve an injection of 
substance into middle or upper spine canal using imaging guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive care management services provided on 
November 16, 2021, by an OON provider. 
 
You asked the Plan to pay for the comprehensive care management services. You say that you are appealing 
the denial. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 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 comprehensive care management services 
provided on November 16, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01926) provided on October 15, 
2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the number of units billed. 
 
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 01926 is anesthesia for urgent hysterectomy following 
delivery. 
 
We find that CPT code 01926 is not supported in the record. Specifically, the documentation does not support 
the 175 units billed. The record indicates that 106 minutes of anesthesia services were rendered. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services (01926) provided on 
October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 30, 
2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 99153 may not be paid 
if furnished to a hospital inpatients or patients in a hospital outpatient 
department. 
 
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 99153 is not supported in the medical record. Specifically, the record indicates that the 
enrollee was in an outpatient hospital setting when this service was rendered. CPT code 99153 has a 
Technical/Professional Component indicator of 3 meaning that this service is the technical component of a 
diagnostic test. Payment for this service is included in the payment to the facility and is the responsibility of the 
facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the moderate 
sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate 
sedation services (99153) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fiber gelling dressing (A6197) provided on October 19, 
2021. 
 
You asked the Plan to pay for the fiber gelling dressing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code A6197 has a status indicator of 
P. 
 
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 A6197 has a Status Indicator of P on the Physician Fee Schedule. This means that CPT 
code A6197 is a bundled/excluded code. There are no payment amounts for this service. No separate payment 
is made for them under the fee schedule.  
 Based on this information, we decided that Medicare rules for coverage of the fiber gelling dressing have not 
been met. Therefore, we decided that the Plan does not have to pay for the fiber gelling dressing (A6197) 
provided on October 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care (99233), provided on September 23, 2021. 
 
 
 
 
 You asked the Plan to pay for the hospital care. You say that the service should be covered. The Plan denied 
your request. The Plan says the member was enrolled in hospice from February 07, 2019, through September 
06, 2021, September 24, 2021, through October 03, 2021, and October 06, 2021, through January 18, 2022. In 
accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, 
for services rendered on September 23, 2021. 
 
Medicare rules say that Original Medicare continues to pay for services furnished after the revocation or 
expiration of the enrollee's hospice election until the first day of the month after the hospice election has been 
revoked or terminated. 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 hospital care (99233), provided on 
September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on October 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 83789 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 83789 (mass spectrometry) and G0480 (definitive drug 
testing). Code 83789 is a column II code with a modifier indicator of 1 when billed with column I code G0480. 
Code 83789 was not billed with an appropriate modifier to allow for separate payment. The -59 modifier is not 
supported as a separate and distinct procedural service. Therefore, we decided that the Plan does not have to 
pay for the mass spectrometry rendered on October 27, 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 11, 2021, to November 26, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $350 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 You have been asked to pay a $1,750 copayment for 5 days of inpatient hospital care ($350 x 5 = $1,750). 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 11, 2021, 
to November 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hyaluronan injections (J7323) provided 
from October 28, 2021, to November 15, 2021. 
 
You asked the Plan to waive the coinsurance for the hyaluronan injections. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided. 
 
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 three hyaluronan injections (allowed is $832.92 x 20% = 
$166.58). Hyaluronan injections fall within the Medicare Part B prescription drugs 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 hyaluronan injections (J7323) provided from October 28, 
2021, to November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 5, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71046. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
March 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid detailed written order. 
 The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on March 8, 2021.
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 June 
1, 2021, to June 4, 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 payment of DRG 193 is not supported, as the review supports DRG 194. 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 193 (SIMPLE PNEUMONIA AND 
PLEURISY WITH 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 was no evidence of treatment consistent with acute respiratory failure such as 
administration of oxygen 5 liters or more, or provision of BiPAP and/or mechanical ventilation. Although the 
provider documented acute respiratory failure with hypoxia, reasonable support within the health record must 
be present for that diagnosis. The review supports that DRG 194 (SIMPLE PNEUMONIA AND PLEURISY 
WITH CC) 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 June 1, 2021, to June 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on November 9, 2021 and 
November 10, 2021. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says the drugs received are not covered by the plan. 
 
 
 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 pay for self-administered drugs received 
on November 9, 2021 and November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on August 
28, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the complete medical 
records for anesthesia services are attached and should be reviewed. The Plan denied your request. The Plan 
says CPT code 01480 has been approved and CPT code 99100 remains denied as bundled services are not 
eligible for separate 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. 
 
In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the special anesthesia service (99100) have 
not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service 
(99100) provided on August 28, 2021.