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

 
We decided that the Plan does not have to waive the copayment for ambulance services received on April 13, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are on a fixed income 
and disagree with the charges. The Plan denied your request. The Plan says the copayment was processed 
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 $300 
copayment for each one-way Medicare-covered ambulance trip.  
 
 
 
 
 
 You have been asked to pay a $300 copayment for ambulance services. The services at issue fall within the 
ambulance 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 ambulance services 
received on April 13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on February 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the claim did not include the required DEX Z-Code. 
 
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 states that the claim didn't include the required DEX Z-Code per Local 
Coverage Determination (LCD) L35025; however, this LCD is not binding for the state of Massachusetts 
where the testing was performed. The Plan has not provided any documentation or Medicare rules to support 
that the testing is not covered. Therefore, we decided that the Plan has to pay for the laboratory services 
rendered on February 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on February 2, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 the rest home visit provided on February 2, 2022 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided in an ambulatory surgical 
center (ASC) on January 18, 2022, billed with code 27599. 
 
You asked the Plan to pay for the ASC services as billed. You say that per coding review of the procedure, it 
was determined that the use of an unlisted code was necessary. Payment for this code should be compared to 
code 27570. The Plan denied your request. The Plan says this code is not payable when billed by an ASC. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a list of all codes that are payable in the 
ASC setting.  
 
 
 
 We looked at the file and Medicare rules. Code 27599 is not listed as a covered ASC code. Payment can only 
be made for services billed with a code that is payable in the ASC setting. Based on this information, we 
decided that Medicare rules for coverage of the ASC services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical services provided in an ambulatory surgical center 
(ASC) on January 18, 2022, billed with code 27599.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided from February 
17, 2022, to March 29, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that you were not told that your 
provider was OON. The Plan denied your request. The Plan says the services received are not a covered benefit 
when provided by an OON provider. 
 
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 the office visit and related services provided from 
February 17, 2022, to March 29, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. 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 February 16, 
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the patient's status is stable and improving. The patient is receiving 
medically necessary acute care and does not have clinical conditions that cannot be appropriately treated in the 
current hospital. 
 
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 the patient is a 54-year-old male with Crohn's disease who was admitted to the acute 
care hospital with partial bowel obstruction and ileostomy prolapse requiring exploratory laparotomy, bladder 
flap closure. The course was complicated by acute kidney failure. He was started on suction and hemodialysis. 
Recent notes describe the patient as still with wound drain from surgery and still requiring total parenteral 
nutrition.  The patient appears to still be somewhat unstable and improving and should only require short-term additional 
acute care services that can safely be administered at the current facility until feeding source is more stable and 
the patient is more appropriate for a lower level of care. The patient does not require services at the LTACH 
that are not already available at the current facility. Transfer to LTACH is not medically necessary as the 
patient is not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at 
the current facility is recommended.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 You asked the Plan to pre-approve Retacrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ESA treatment is not reasonable and necessary for 
beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their 
underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. 
 
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 Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the records show that the iron deficiency 
anemia as responded to iron with a current hemoglobin of 11.5 which is not severe enough to meet criteria for 
epoetin therapy. Therefore, this request for Retacrit is not supported in the documentation and does not meet 
coverage criteria in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for nurse practitioner services provided from January 31, 2022, to February 
23, 2022. 
 
You asked the Plan to pay for the nurse practitioner services. You say that the Plan has processed these claims 
under an incorrect provider. The Plan denied your request. The Plan says that these claims were processed 
correctly according to the "Macess Images." 
 
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 claims clearly indicate that a nurse practitioner is the rendering 
provider.  The nurse practitioner's name and National Provider Identifier (NPI) is appropriately on the claim.  
For some reason, the Plan's claim system has allocated these claims to a chiropractor who doesn't even work in 
the same practice as the nurse practitioner who rendered the services.  The Plan has provided no explanation as 
to how that came to be.  The Plan has provided no explanation to what "Macess Images" are, nor has the Plan 
included any such substantiating documentation in the file.  It is clear that the nurse practitioner is the 
appropriate billing provider.  The burden is on the Plan to prove that its denial is appropriate.  Because the Plan 
has failed to provide any documentation or support for why it has changed the billing provider on these claims, 
we find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for nurse 
practitioner services provided from January 31, 2022, to February 23, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glucose blood test coded 82962 provided on November 
30, 2021. 
 
You asked the Plan to pay for the glucose blood test. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation is missing required information. 
 
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 82962 is glucose, blood by glucose monitoring device(s) 
cleared by the FDA specifically for home use. 
 
 
 We find that CPT code 82962 is not supported in the medical record. Specifically, the documentation did not 
include medical records. Without this information, the documentation does not support how the enrollee came 
to the servicing provider or whether the services rendered were medically necessary. Based on this information, 
we decided that Medicare rules for coverage of the glucose blood test have not been met. Therefore, we 
decided that the Plan does not have to pay for the glucose blood test coded 82962 provided on November 30, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician pathology services (88342, 88360) billed for date 
of service June 7, 2021. 
 
You asked the Plan to pay for pathology services. You say that these services were billed appropriately and 
should be paid. The Plan denied your request. The Plan says these services were not billed in accordance with 
Medicare regulations and are missing a necessary modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88342 and 88360 are physician pathology services which have both professional 
components (PC) and technical components. These services were not billed with modifier 26 to indicate that 
only the professional component payment is requested. This means that payment is requested for both the PC 
and TC of these services. However, these services were provided to an enrollee who was in an outpatient 
hospital setting at the time the sample was collected, which means that the TC component is bundled into the 
facility payment. The TC portion of these services are not separately payable, and therefore these services are 
not supported as billed. Based on this information, we decided that Medicare rules for coverage of pathology 
services have not been met. Therefore, we decided that the Plan does not have to pay for physician pathology 
services (88342, 88360) billed for date of service June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided in conjunction 
with an annual physical on May 16, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you thought the lab tests were a 
part of the annual physical. 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 $10 
copayment for lab services.  
 
The file shows that Medicare rules say that certain lab tests are included with an annual physical. In this case, a 
comprehensive metabolic panel and urinalysis were also performed. These tests go beyond the scope of routine 
testing and are subject to separate cost sharing. Therefore, you have been asked to pay a $10 copayment for the 
lab services. The lab services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
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 laboratory services provided in 
conjunction with an annual physical on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93793 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 93793. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is not separately payable from code 
99214.  Code 99214 was billed by the same medical group on the same date of service. 
 
 
 
 
 
 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 93793 
is a column II code to column I code 99214 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 93793 billed for date of service March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 9, 
2021, to November 5, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that you had authorization for these services. 
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 October 9, 2021, to November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0667, E0651). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for a Pneumatic Compression Device to be covered, a 
six-month trial of conservative therapy demonstrating failed response to treatment is required. 
 
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 pneumatic compression device. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found the records 
provided do not adequately document a 6 month trial of conservative therapy as described in the coverage rule. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0667, E0651).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service February 14, 2022. 
 
You asked the Plan to pay for code 99222. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect POS on the claim. The Plan 
must follow Medicare rules. Medicare rules say that providers must enter the correct Place of Service (POS) 
code on the claim form. POS 21 represents inpatient hospital services. POS 22 represents on-campus outpatient 
hospital. In this case, you billed this service with POS 21, indicating inpatient hospital.  However, the claims 
history shows that this patient was not an inpatient but were in an outpatient observation stay on this date of 
service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 99222 billed for date of service February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing billed with procedure code 81232 for date of 
service January 18, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the genetic testing at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for genetic testing have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 81232 is not supported in the medical record for the billed date of service. Specifically, 
the medical record indicates that the specimen was collected on December 22, 2021. Based on this information, 
we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing billed with procedure code 81232 for date of service January 
18, 2022.