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

 
We decided that the Plan does not have to pre-approve treatment with Celebrex capsule. 
 
You asked the Plan to pre-approve Celebrex capsule. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Celebrex 
capsule.  
 
Benefits for Celebrex capsule 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 GEMTESA. 
 
You asked the Plan to pre-approve GEMTESA. The Plan denied your request. The Plan says this is not covered 
under the enrollee's Part B 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 pre-approve GEMTESA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies (99072), the IV tubing extension set 
(S1015), and the infection control supplies (S8301) provided on April 22, 2021. 
 
You asked the Plan to pay for codes 99072, S1015, and S8301. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Codes S1015 and S8301 
have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid 
for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, 
we decided that the Plan does not have to pay for the additional supplies (99072), the IV tubing extension set 
(S1015), and the infection control supplies (S8301) provided on April 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency services (procedure code 99285) provided to the 
enrollee on 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 there is a more appropriate diagnosis code that indicates laterality. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 not supported by the medical records. Our reviewer found medical decision making of high 
complexity was not documented and according to the ICD-10-CM Official Guidelines for Coding and 
Reporting, some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, 
right, or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes, when a more 
specific code is available 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for emergency services (procedure code 99285) provided to the enrollee on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital bed to be provided by an opt-out provider. 
 
You asked the Plan to pay for the bed. You say that these claims were paid in the past. The Plan denied your 
request. The Plan says the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal are to be provided in a non-urgent, non-emergent situation by the provider 
who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a 
hospital bed to be provided by an opt-out provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve additional services. You say that the enrollee needs to complete her 
treatment plan. The Plan denied your request. The Plan says any gains can be maintained through a home 
exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional services. Our physician 
reviewer found that the documentation indicates the enrollee's goal is to sit straighter in a chair and look over 
her left shoulder when someone is talking to her.  Her right sided headache has not been noted since last adjustment. Her cervical range of motion is restricted 
and causes pain. She was advised on a home care plan. The additional requested therapy is not generally 
accepted as effective therapy for the enrollee's condition beyond what was approved by the Plan. The records 
do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the 
services can be performed only by a therapist, or under the supervision of a therapist. The enrollee can 
transition to a home exercise program. The requested services are not required to establish, design or deliver a 
program to maintain her current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure G0483) provided to the 
enrollee on January 20, 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 the denied code remains not supported. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code 
G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."  
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 drug testing services (procedure 
G0483) provided to the enrollee on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204, G8427, G9903, G9744, G8420) 
provided on April 19, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
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 an office visit (99204, G8427, G9903, G9744, G8420) provided on April 
19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that you would like 
reconsideration because you have upcoming doctors appointments and no way to get there The Plan denied 
your request. The Plan says you have exhausted your non-emergency transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Baclofen. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary to help with back muscle 
spasms. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited 
benefits for prescription drugs. 
 
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 Baclofen.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on March 23, 2021.  
You asked the Plan to pay for the ambulance transportation. You say that the Plan's website does not show that 
the enrollee was an inpatient during these dates. The Plan denied your request. The Plan says a claim was 
received for inpatient psychiatric care provided from March 12, 2021, through April 6, 2021. As such, no 
payment can be made for this transport. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment is not made for ambulance 
services provided during an inpatient hospital stay. For those in an IPF, an additional edit allows separate 
payment if occurrence span code 74 is reported on the hospital claim, and the date of service falls within that 
span plus one day.  
 
This claim's date of service is within an inpatient confinement. The IPF claim does not include occurrence span 
code 74. As such, no separate payment can be made for this trip. Therefore, we decided that the Plan does not 
have to pay for the ambulance transportation provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99336) provided on February 15, 2021 to February 16, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your 
request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 physician services (99336) 
provided on February 15, 2021 to February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you are dissatisfied with the in-network 
provider, and you do not want to change providers. The Plan denied your request. The Plan says the provider is 
out-of-network. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labs services (87481, 88312, 87798, 88305) provided on April 10, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your 
request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 labs services (87481, 88312, 87798, 88305) provided on April 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided to the enrollee from March 25, 2021, 
to March 29, 2021. 
 
You asked the Plan to pay for inpatient care. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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. 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 inpatient care. Our reviewer says that Medicare criteria are not met. Our physician reviewer found the 
enrollee was treated as an inpatient for services with major complication or morbidity. The documentation 
submitted was reviewed and does not meet the required criteria. These records show no mention of acute 
kidney failure with tubular necrosis. (ICD 10 N17.0). Therefore, this diagnosis cannot be verified as a 
condition of inpatient care.  
 
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 care provided to the enrollee from March 25, 2021, to March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee from November 11, 
2020 to November 13, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. We note the Plan is stating 22326 and 22600 are 
being handled under separate appeal but no evidence of this. these codes need to be reviewed. The Plan states  
22842 and 22842-59 have been approved and 20930, 20936, 27216 and 27217 are all being denied based on 
not being by Medicare. 
 
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 
this service.  Our reviewer says that Medicare coverage criteria are not met. Our reviewer found the enrollee is a 58-yr old 
male billed for code 22600 - Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 
segment, and Current Procedural Terminology (CPT) 22326 - Open treatment and/or reduction of vertebral 
fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical.  The 
documentation submitted was reviewed and does not meet coverage criteria. The records state code 22326 -Per 
Documentation 2 procedures were performed.  Code 22326 was performed in first procedure.  Operative report 
documents "Procedure 1: Open treatment of C5/6 cervical fracture - 22326".  However, operative report did not 
include documentation of open treatment of C5/6, and therefore cannot be verified.  Unable to cite report, as 
this service was not documented. Fore code 22600 the documentation shows two procedures were performed.  
Code 22600 was performed in the first procedure. The operative report documents "Procedure 1: Posterior 
cervical arthrodesis C3 to C7 - 22600, 22614 x 3". The operative report does not include enough detail to 
confirm this procedure. Per the operative report "We then decorticated from C3 to C7.?  Confirmation cannot 
be made a spinal fusion 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee from November 11, 2020 to November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunizations provided on May 18, 2021. 
 
You asked the Plan to pay for the immunizations. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the immunizations are not covered under your Medicare Part B 
benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunizations. The Plan 
follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunizations. 
Therefore, we decided that the Plan does not have to pay for the immunizations provided on May 18, 2021.  
 
Benefits for the immunizations 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive your copayment for ambulance services you received on 
March 1, 2021. 
 
You asked the Plan to waive your copayment for the ambulance services. You say that you went for your 
COVID-19 shot and had a reaction.  The nurses suggested that you take an ambulance to the emergency room. 
You thought there was no copayment for anything related to COVID-19. The Plan denied your request. The 
Plan says you were charged this copayment 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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless 
of the reason for the ambulance services.  In addition, the Plan's website states that only COVID-19 testing and 
vaccinations are copayment-free. Any other COVID-19 related treatment still applies your normal cost sharing. 
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 your copayment for ambulance services you received on March 1, 2021.