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

 
We decided that the Plan does not have to pay for subsequent nursing facility care (code 99309) provided on 
January 3, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care (code 99309). You say that the medical records 
support this code. The Plan denied your request. The Plan says the medical records meet the criteria for code 
99308. 
 
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 99309 is subsequent nursing facility care. 
 
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 subsequent nursing facility care. Our 
physician reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the enrollee was a then 79-year-old female resident of a skilled nursing facility. She was evaluated on January 3, 2022 for follow-up L1-L2 fracture. The enrollee has been wearing a TSLO 
brace. Having issues with constipation for Tramadol and immobility. The enrollee was to continue brace and 
prn analgesics. The review has determined that the records support code 99308. There was no medical decision 
making of moderate complexity. There was no development of a significant complication or a significant new 
problem. 
 
We looked at this physician review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent nursing facility care (code 99309) have not been met. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care (code 99309) provided on 
January 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on January 3, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim should be reimbursed at air ambulance rates 
rather than ground ambulance rates. The Plan denied your request. The Plan says ground ambulance services 
would not have posed a threat to survival or health. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 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 medically reasonable or necessary. Our physician reviewer found that the 
documentation supports that the patient suffers from an illness or injury that contraindicates transportation by 
any means other than ambulance. The patient had a compound fracture of the ankle and transportation by 
ambulance was medically necessary. However, the documentation does not support that the patient's condition 
was such that the time needed to transport a patient by ground, or the instability of transportation by ground, 
posed a threat to the patient's survival or seriously endangered the patient's health. The documentation stated 
that patient requested transport to a hospital in Oklahoma City, rather than a close hospital in Tulsa, because 
she was already an established patient in Oklahoma City. There were hospitals with orthopedic services which 
could have managed the injury within ground transport range. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services provided to the enrollee on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on October 22, 2021. 
 
You asked the Plan to waive the copayment for urgent care. You say that you want to appeal the amount being 
charged. 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 $50 
copayment per visit for urgently needed care. Urgently needed services are provided to treat a non-emergency, 
unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services 
may be furnished by network providers or by out-of-network providers when network providers are 
temporarily unavailable or inaccessible.  
 
You have been asked to pay a $50 copayment for urgent care. This item/service falls within the Urgently 
needed services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgent care on October 22, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided on March 07, 2022, to 
April 01, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you thought this would be covered in 
full. 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 
$1,624.68 copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $1,624.68 copayment for SNF care. This item/service falls within the Skilled 
nursing facility (SNF) care 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 SNF care 
provided on March 07, 2022, to April 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 19, 
2022, to March 21, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were made to stay an extra 
day that you feel was unnecessary. You feel you should only have to pay $225, not $450. 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 $225 
copayment per day for days 1-7 for inpatient hospital care ($225 x 2 days = $450).  
 
You have been asked to pay a $450 copayment for an inpatient stay. This item/service falls within the inpatient 
hospital care 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 an inpatient stay provided 
from March 19, 2022, to March 21, 2022.
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 
November 21, 2021, to November 23, 2021. 
 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
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 diagnosis code M62.82 - rhabdomyolysis. 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 inpatient hospital services at the DRG originally 
billed. Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that while the physician also diagnosed the patient with rhabdomyolysis, the clinical 
evidence did not support the condition. The CK was only minimally elevated at 319 with a facility upper limit 
of normal of 308. In addition, review of the medical record found no evidence of myoglobinuria. The review 
has determined that the records did not support the use of diagnosis code M62.82 - rhabdomyolysis.  
 
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 November 21, 2021, to November 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on 
February 21, 2022, to June 22, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you need this care and 
having to pay $40 copayment for each visit is too much money. 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 $720 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $720 copayment for physical therapy visits. This item/service falls within the 
Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for 
physical therapy visits provided on February 21, 2022, to June 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided on June 
21, 2022. 
 
You asked the Plan to waive the copayment for diagnostic mammogram. You say that this was just a routine 
mammogram and you shouldnt be charged. 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 basic imaging services. 
 
You have been asked to pay a $35 copayment for diagnostic mammogram. This item/service falls within the 
basic imaging services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for diagnostic 
mammogram provided on June 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplicate intravascular ultrasound provided to the enrollee 
on April 25, 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 medical records contain two duplicate procedure reports. 
 
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 the duplicate CPT code 37253 is not supported in the medical record. Specifically, there is no 
evidence that two separate services were performed. The reports in the case file are duplicates of one another. 
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 a duplicate intravascular ultrasound provided to 
the enrollee on April 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on April 13, 2022, to 
May 27, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. 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 $325 
copayment for Medicare covered surgical services (including diagnostic colonoscopy) at outpatient hospital. If 
you are having surgery in a hospital facility, you should check with your provider about whether you will be an 
inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are 
an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital 
overnight, you might still be considered an outpatient. There were 2 dates of service. 2 x $325 = $650. 
Therefore, results in the total cost sharing amount of $650.  
 
 You have been asked to pay a $325 copayment for each outpatient surgery. This item/service falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery on April 13, 
2022, to May 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided on March 09, 2022, to 
March 28, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you received inadequate medical 
treatment so 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 a $2,820 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $2,820 copayment for SNF care. This item/service falls within the Skilled 
nursing facility (SNF) care 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 SNF care 
provided on March 09, 2022, to March 28, 2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the enrollee is with a history of low back pain related to lumbar radiculopathy and spinal 
stenosis. The enrollee's last interlaminar epidural steroid injection (ESI) of L5-S1 was on September 6, 2022, 
with 90% pain relief for two weeks then had a gradual decline in relief. The provider has requested a repeat 
ESI. The enrollee states after his ESI injection he was able to bend to pick up item and get out of bed with no pain. According to the coverage criteria, a repeat epidural steroid injection is indicated if there has been at least 
50% improvement of pain for a duration of at least 3 months. The enrollee does not meet the coverage 
indications for the requested epidural. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on May 05, 2022, to 
May 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $390 
copayment per day, days 1 to 5; $0 copayment per day, days 6 to 90 for inpatient hospital stay. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. The day 
before you are discharged is your last inpatient day. 5 x $390 = $1,950. Therefore, results in the total cost 
sharing amount of $1,950. 
 
 
 You have been asked to pay a $390 copayment per day for inpatient hospital stay. This item/service falls within 
the Inpatient hospital care 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 inpatient 
hospital stay on May 05, 2022, to May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on 
December 4, 2021. 
 
You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the monitor. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that 
based on the medical records provided there is no documentation that the enrollee is insulin treated with three 
or more daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. 
There is no documentation that the enrollee's insulin treatment regimen requires frequent adjustment by the 
enrollee on the basis of blood glucose monitor of continuous glucose monitor testing results. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pay for a continuous glucose monitor provided to the enrollee on December 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72052 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 72052. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 72052 is bundled into payment for code 72082. 
 
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 72052 
is a column II code to column I code 72082. 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 72052 billed for date of service May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 22, 2022.