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

 
We decided that the Plan does not have to pay for codes 96361, A4930, and S1015 for services provided on 
June 17, 2022. 
 
You asked the Plan to pay for codes 96361, A4930, and S1015. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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.  
We find that CPT codes 96361, A4930, and S1015 are not supported in the medical record. Specifically,  
The intravenous (IV) catheter was inserted at 22:00, normal saline was ordered a 1000 ml/hour, and the 
infusion was stopped at 23:00. The submitted records do not include documentation of intravenous infusion, 
hydration beyond 1 hour being performed on the date of service. Therefore, code 96361 Intravenous infusion, 
hydration; each additional hour (List separately in addition to code for primary procedure) cannot be verified. 
 
Code A4930 has a status code of X. A status code of X means that this code is a statutory exclusion. These 
codes represent an item or service that is not in the statutory definition of physician services for fee schedule 
payment purposes. No RVUs or payment amounts are shown for these codes and no payment may be made 
under the physician fee schedule. This means code A4930 is not payable as billed. 
 
We find that procedure code S1015 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S1015 is not valid for Medicare purposes. 
 
Based on this information, we decided that Medicare rules for coverage of codes 96361, A4930, and S1015 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 96361, A4930, and 
S1015 for services provided on June 17, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport, (A0428), and ground mileage (A0425) provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically 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 ambulance service, basic life support, non-emergency 
transport, (A0428), and ground mileage (A0425) provided on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that aggressive care will aide in your 
recovery and help you regain your full function. The Plan denied your request. The Plan says LTACH services 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not available at the acute care 
hospital or the skilled nursing facility.  The requested treatments are not medically necessary at the LTACH 
level of care.  The enrollee has improved medically and can receive further care at the current acute care 
hospital or a lower level of care when deemed appropriate. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99215) provided on 
September 23, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit (99215). You say that the technician 
dilated your eyes before the provider had a chance to see you, so you had to reschedule. You also say you 
should not be penalized due to the technician. 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 $35 
copayment for in-person specialist visit. 
 
You have been asked to pay a $35 copayment for a specialist office visit (99215). This item/service falls within 
the in-person specialist visit 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 a specialist 
office visit (99215) provided on September 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 18 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 18 routine transportation trips. You say that the enrollee needs 
transportation to medical appointments. The Plan denied your request. The Plan says the enrollee has utilized 
the maximum number of transportation trips allowed per year. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 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 an additional 18 routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient admission from December 3, 2022, 
forward. 
 
You asked the Plan to pre-approve continued inpatient admission from December 3, 2022, forward. You say 
that the services are medically necessary. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
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 continued inpatient admission from 
December 3, 2022, forward. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the progress notes describe the enrollee 
with stable vitals, responding to the then current antibiotic regimen with improving oral intake by December 3, 
2022, suggesting only needing observation level of care. The request for continued inpatient services after 
December 3, 2022, was not supported in the documentation and will be considered not medically necessary as 
the enrollee was stable.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient admission from December 3, 2022, forward have not been 
met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient admission from 
December 3, 2022, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73070 billed for date of service June 12, 
2022. 
 
You asked the Plan to pay for procedure code 73070. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 73070 is bundled into 
payment for code 73080. 
 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 73070 
is a column II code to column I code 73080. 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 73070 billed for date of service June 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete set of intraoral x-rays (D0210) provided on 
April 15, 2022. 
 
You asked the Plan to pay for the complete set of intraoral x-rays (D0210). You say that you were advised that 
your insurance would pay 100% and now you are getting bills in the mail. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage the complete set of intraoral x-rays 
(D0210) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the complete set of intraoral x-rays (D0210) provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99203) provided on December 21, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that this claim is being 
processed under Physical Therapy. You say that all of the providers are medical doctors (MD). You also say 
that evaluation and management codes are billable for MD. The Plan denied your request. The Plan says that 
evaluation and management services are not covered for this specialty or provider type. 
 
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. Specifically, the file does not support the Plan's reasoning for their denial. 
Therefore, we decided that the Plan has to pay for the office visit (99203) provided on December 21, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on March 21, 2022.
You asked the Plan to waive the coinsurance for Part B drugs. You say that this should be covered. 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 20%
coinsurance for Medicare Part B prescription drugs.

You have been asked to pay $66.67 which is 20% of the allowed amount for Part B drugs. The allowed amount
is $333.34 (20% x $333.34= $66.67). This item/service falls 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 Part B drugs provided on March
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lumbar Transforaminal Epidural Injection at Bilateral 
L5-S1 spinal level (64483). 
 
You asked the Plan to pre-approve a Lumbar Transforaminal Epidural Injection at Bilateral L5-S1 spinal level. 
You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in  unction measured from baseline using SAME scale* for at least three months. If a patient fails 
to respond well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level 
and/or medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. 
 
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 Lumbar Transforaminal Epidural 
Injection at Bilateral L5-S1 spinal level. Our reviewer says that the service is not medically necessary. Our physician reviewer found the duration of relief provided by the prior injection was not documented to be at 
least 50 percent for at least three months. 
 
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 Lumbar Transforaminal Epidural Injection at Bilateral L5-S1 spinal level have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Lumbar Transforaminal 
Epidural Injection at Bilateral L5-S1 spinal level (64483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and the ophthalmic diagnostic imaging 
provided on August 1, 2022. 
 
You asked the Plan to pay for the eye exam and the ophthalmic diagnostic imaging. You say that the provider 
was in-network, and the services were provided in good faith. The Plan denied your request. The Plan says 
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 did not pre-approve the 
eye exam and the ophthalmic diagnostic imaging. We found no exception that would require the Plan to pay for 
the eye exam and the ophthalmic diagnostic imaging. Therefore, we decided that the Plan does not have to pay 
for the eye exam and the ophthalmic diagnostic imaging provided on August 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on June 07, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be covered. 
 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 skilled nursing facility provided on June 07, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sphincteroplasty, anal, for incontinence, adult; levator 
muscle imbrication (Park posterior anal repair) provided to the enrollee on January 4, 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 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. 
 
In this case, the CPT Code Manual definition of code 46761 is "Sphincteroplasty, anal, for incontinence, adult; 
levator muscle imbrication (Park posterior anal repair)." 
 
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 that the operative report describes two 
procedures performed in same anatomical area, anal sphincteroplasty and excision of rectal procidentia. In this 
case, the most comprehensive procedure (CPT 45130) should be reported. 
 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 sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal 
repair) provided to the enrollee on January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is not able to participate in, tolerate, or benefit from intensive therapy. 
The enrollee does not require frequent physiatry oversight. The enrollee's level of cognitive loss is best 
addressed outside the intensity of a hospital setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80076, 82140) provided on 
April 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically 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 laboratory services (36415, 80076, 82140) provided on 
April 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2022.