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

 
We decided that the Plan does not have to pay for anesthesia services (01992) provided November 19, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid primary diagnosis. 
 
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 01992 is not supported in the medical record. Specifically, Z53.9 is not a valid principle 
diagnosis. 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 anesthesia services (01992) 
provided November 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 testing services (U0003L, U0005L) provided on 
January 11, 2022. 
 
You asked the Plan to pay for the COVID-19 testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that COVID-19 
vaccinations will be billed through the Medicare Fee For Service program. 
 
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. In this case, the Plan has denied payment for the billed COVID-19 testing 
services stating that COVID-19 vaccinations must be billed to Original Medicare. The services at issue are not 
COVID-19 vaccinations but COVID-19 testing. The Plan has not sufficiently backed up their denial of 
COVID-19 testing services in this case as no valid argument has been presented why the testing billed cannot 
be paid. Therefore, we decided that the Plan has to pay for the COVID-19 testing services (U0003L, U0005L) 
provided on January 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on November 11, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
information needed was not provided. 
 The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
The file shows that knee orthoses, suspensions sleeves, and a lumbar orthosis was provided. We looked at the 
file and Medicare rules. The records do not include a physical examination, diagnostic tests, or documentation 
for past treatment for the enrollees issues. It appears that the orthoses may have been ordered by an unsolicited 
outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's 
treating physician. The record does not show that contact was initiated regarding an item already furnished to 
the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the orthoses provided on November 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa capsules. 
 
You asked the Plan to pre-approve Vascepa capsules. The Plan denied your request. The Plan says this drug is 
not covered under the enrollee's contract under any normal circumstances. 
 
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 Vascepa capsules.  
 
Benefits for Vascepa capsules 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on August 26, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the medical 
records do not support the coding criteria. 
 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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records 
provided show that a drug screening was ordered. The records do not show that testing of 22 classes was 
provided or necessary due to suspicious behaviors, self-escalation of dose, doctor-shopping, indications of 
illegal drug use, or other clinician documented change in affect or behavioral pattern. 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 drug testing services provided on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
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 lab 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 lab services provided on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve various drugs associated with a clinical trial. 
 
You asked the Plan to pre-approve various drugs. You say that these drugs are medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says these drugs would be considered a routine 
cost associated with a clinical trial.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve various drugs as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve various drugs associated with a clinical trial.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 25, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was a then 66 year old male with a history of hypertension, asthma, obesity, non-
obstructive coronary artery disease and hypersensitivity lung disease who presented to the emergency room on 
February 25, 2022, via EMS with complaints of chest pain. He was evaluated; EKG was sinus rhythm with 
right bundle branch block/left anterior fascicular block. He was given acetylsalicilic acid and placed on cardiac 
monitoring. Cardiac biomarkers were normal. He was evaluated by Cardiology and underwent coronary 
catheterization on February 28, 2022. He required no interventions and was discharged home later that day. 
The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 25, 2022, to February 28, 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 lab services (81206, 81275, 81276, 81301) provided October 
20, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81206, 81275, 81276, 81301) 
provided October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on January 11, 
2022. 
 
You asked the Plan to pay for subsequent hospital care (99233). You say that the patient had two visits on the 
same date with different physicians and different primary diagnosis codes. You say that this is not a duplicate 
and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 99233 is not 
allowed when billed on the same date as 99222. 
 
  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 99233 
is a column II code to column I code 99222 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for subsequent hospital care (99233) provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 lab 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 lab services provided on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for optometry services (65778) provided March 23, 2021. 
 
You asked the Plan to pay for the optometry services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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 65778 is Placement of 
amniotic membrane on the ocular surface; without sutures. 
 
We find that CPT code 65778 is not supported in the medical record. Specifically, no procedure report was 
provided to document this service. Based on this information, we decided that Medicare rules for coverage of 
the optometry services have not been met. Therefore, we decided that the Plan does not have to pay for 
optometry services (65778) provided March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diovan. 
 
You asked the Plan to pre-approve Diovan. You say that the enrollee has hypertension and proteinuria. You say 
that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested 
medication does not fall under Part B coverage. The Plan says that they do not administer pharmacy benefits 
for the enrollee. The Plan says that the enrollee's prescription coverage is provided through Express Scripts. 
 
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 Diovan.  
 Benefits for Diovan 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for patient of extreme age (99100) provided 
on November 10, 2021. 
 
You asked the Plan to pay for the anesthesia for patient of extreme age. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says no separate payment is 
made for these services. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia for patient of extreme age have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia for patient of extreme age (99100) provided on November 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone tablets. 
 
You asked the Plan to pre-approve Dexamethasone tablets. You say that it is very important that the enrollee 
receives this medication because they have been on it for some time, and it is effective. The Plan denied your 
request. The Plan says this medication does not fall under Part B. 
 
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 Dexamethasone tablets.  
 
Benefits for Dexamethasone tablets 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Labetalol 100mg tablets. 
 
You asked the Plan to pre-approve Labetalol 100mg tablets. The Plan denied your request. The Plan says this 
drug is not covered under the enrollee's contract under any normal circumstances. 
 
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 Labetalol 100mg tablets.  
 
Benefits for Labetalol 100mg tablets 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgery services (28005, 28122, 28820) provided on June 17, 2021. 
 
You asked the Plan to pay for the surgery services. You say that you would like this claim reprocessed based 
on the medical records that have been submitted. The Plan denied your request. The Plan says that originally, 
this case denied because coding standards were not met. Specifically, the documentation that was provided was 
not legible. The Plan then did not make a timely decision and auto forwarded the case. 
 
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. In this case, the medical records that were submitted were completely legible. 
There is no support for the Plan continuing their denial based on this reasoning. Therefore, we decided that the 
Plan has to pay for the surgery services (28005, 28122, 28820) provided on June 17, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided from August 30, 
2021, to September 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that there were gaps in productivity. The Plan 
denied your request. The Plan says that the claim was not filed within the required time limit. 
 
The Plan must follow Medicare rules. The rules say that claims for services furnished on or after January 1, 
2010, must be filed no later than one calendar year after the date of service. 
 
We looked at the file and the rules. The record shows that a claim for the services at issue was filed less than 
one calendar year from the date of service. Based on this information, we decided that the Medicare rules for 
payment have been met. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the evaluation and management services provided from August 30, 2021, to September 8, 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 testing services provided on February 18, 2021. 
 
You asked the Plan to pay for the testing services. You say that the lab work should be covered. The Plan 
denied your request. The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until March 10, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the calculi removal and stent placement procedure provided 
on March 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the calculi removal and stent placement procedure. You say that the services 
were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
calculi removal and stent placement procedure. We found no exception that would require the Plan to pay for 
the calculi removal and stent placement procedure. The records provided for review do not show that the 
services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the 
calculi removal and stent placement procedure provided on March 1, 2022, by an out-of-network (OON) 
provider.