Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from 
May 11, 2021, to May 21, 2021. 
 
You asked the Plan to pay for the services. You say that a valid code was used. The Plan denied your request. 
The Plan says that the submitted Health Insurance Prospective Payment System (HIPPS) code PAPD1 is 
incorrect. 
 
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. The plan has not sufficiently explained why PAPD1 is not a valid code in this 
case. They have not explain to the provider how to correct the supposed error. Therefore, we decided that the 
Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from May 11, 2021, to May 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on January 19, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you feel you should not have to pay this bill 
as you were not transported. The Plan denied your request. The Plan says since no transport was provided there 
is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exotosis represented by code 
D7471. 
 
You asked the Plan to pre-approve the removal of lateral exotosis. You say that the requested procedure is 
medically necessary. The Plan denied your request. The Plan says the requested service is not covered under 
the enrollee's benefit package. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of lateral exotosis represented by code D7471.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 22, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
October 19, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the physician only provided medically 
necessary services in good faith. 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 subsequent nursing facility care (99308) provided on 
October 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from January 12, 2022, to February 1, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that money is tight right now. The Plan 
denied your request. The Plan says the copayment was applied 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 for each admission you pay 
$20 per day for days 1-20 of a benefit period, and $80 per day for days 21-44 of a benefit period, and $0 per 
day for days 45-100 of a benefit period. .  
 
 
  You have been asked to pay $400 ($20 a day x 20 days) for the SNF stay. The SNF stay 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 a skilled 
nursing facility (SNF) stay provided from January 12, 2022, to February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman Spinal Simplicity interspinous device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for treatment of the health 
problem. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental for use in spine surgery. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Minuteman Spinal Simplicity interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic CGM. You say that this device is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
therapeutic continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99308, 93321, and 93325 billed for date of 
service February 4, 2022. 
 
You asked the Plan to pay for procedure codes 99308, 93321, and 93325. The Plan denied your request. The 
Plan says payment for codes 99308, 93321, and 93325 is bundled into payment for code 33016. 
 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 codes 
99308, 93321, and 93325 are column II codes to column I code 33016. 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 codes 99308, 93321, and 93325 
billed for date of service February 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 4, 2021, to July 7, 
2021, as billed with Diagnosis Related Group (DRG) 872. 
 
You asked the Plan to pay for inpatient care as billed with DRG 872. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not appropriate as the diagnoses of sepsis due to E. coli (A41.51) and severe sepsis without septic shock 
(R65.20) are not supported in the medical record. The Plan argues that DRG 690 is more appropriate in this 
case. 
 
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 as billed with DRG 872. Our 
reviewer says that the diagnoses of sepsis due to E. coli (A41.51) and severe sepsis without septic shock 
(R65.20) are not supported in the medical record for this inpatient admission. Our physician reviewer found 
that the enrollee presented to the facility with the chief complaint of progressive malaise and fever. While it is 
acknowledged the enrollee was supported by the provider examinations to be "ill appearing" and in "acute 
distress", the medical record and provider documentation was unclear related to a dysregulated response to 
infection. Diagnostic data noted that the enrollees white blood cell count was within normal range at 
presentation at 9.4 and remained within normal range until the day of discharge when it was 3.7, and the 
laboratory data also reflected normal platelet, creatinine, and total bilirubin levels during the 3-day encounter. 
Mental status was documented to be normal and Glasgow coma scale scores were 15, with no support of 
infection induced mental status changes. Saturations at presentation were documented to be "normal" at 93 
percent, and the provider did not support acute abnormalities in oxygenation. Vital signs also noted mean 
arterial blood pressure values greater than 70 mmHg, with notations of warm and dry skin without color 
abnormality. There was no clinical or laboratory evidence of sepsis. The review has determined that the 
medical records do not support the billing of sepsis due to E. coli (A41.51) and severe sepsis without septic 
shock (R65.20). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 872 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from July 4, 2021, to July 7, 
2021, as billed with Diagnosis Related Group (DRG) 872.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for omalizumab injections on January 20, 
2022, and February 17, 2022. 
 
You asked the Plan to waive the coinsurance for omalizumab injections. You say that you would like to request 
reconsideration of the claim. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for omalizumab injections. The total coinsurance owed is $918.18. 
 
You have been asked to pay 20% coinsurance for omalizumab injections. omalizumab injections 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 omalizumab injections on January 20, 2022, and February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ranibizumab injections on January 4, 
2022, and February 1, 2022. 
 
You asked the Plan to waive the coinsurance for ranibizumab injections. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for ranibizumab injections. The total allowed amount of the injections is $3,152.9, resulting in a 
coinsurance amount of $315.30. 
 
You have been asked to pay 10% coinsurance for ranibizumab injections. ranibizumab injections 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 ranibizumab injections on January 4, 2022, and February 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided 
from March 15, 2022, to March 25, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you have received conflicting 
information from the plan and provider about these services. The Plan denied your request. The Plan says the 
copayment was applied 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 $40 per 
day for in-network Medicare-covered physical therapy services.  
 
You have been asked to pay $200 ($40 copay x 5 sessions) for the PT services. The PT services 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 (PT) services provided from March 15, 2022, to March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgical skin graft provided 
on March 8, 2021. 
 
You asked the Plan to waive the copayment for an outpatient surgical skin graft. You say that you should not 
have this copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $380 
copayment for an outpatient surgery.  
 
You have been asked to pay a $380 copayment for an outpatient surgical skin graft. An outpatient surgical skin 
graft falls within the Outpatient Surgery 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 outpatient surgical skin graft provided on March 8, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional physical therapy sessions provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy sessions. You say that additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says that the medical criteria for additional PT has not been 
met. 
 
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 physical therapy sessions. Our reviewer 
says that additional physical therapy sessions are medically necessary. Our physician reviewer found spasticity 
is a neurological condition which would require the assessment and treatment of a professional physical 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy sessions have been met. Therefore, we decided that the Plan 
has to pre-approve 10 additional physical therapy sessions provided by a participating provider. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation 
in the Inpatient Rehabilitation Facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be 
at/nearing a new plateau in function. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, 
can, as a practical matter, be provided at a lower level of care. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nasal endoscopy performed on August 
16, 2021. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you paid all of your copayments 
and received this bill months later. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $125 
copayment for each visit to an ambulatory surgical center.  
 
You have been asked to pay a $125 copayment for the endoscopy. The endoscopy is considered a surgical 
procedure and 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 a 
nasal endoscopy performed on August 16, 2021.