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

We decided that the Plan does not have to pay for surgical services (procedure code 10061) provided to the
enrollee on March 22, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 10061 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 10061 is "Incision and drainage of abscess (eg, carbuncle,
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or
multiple."
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 in this case record indicates that
the enrollee underwent a procedure. The operative note does not indicate the presence of a complicated lesion
or multiple abscesses
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 surgical services (procedure code 10061) provided to the enrollee on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network
(OON) provider on July 7, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on July 7,
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (procedure code 99601) provided to the
enrollee from March 26, 2021 to March 30, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this 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 CPT code.
In this case, the CPT Code Manual definition of code 99601 is "Home infusion/specialty drug administration,
per visit (up to 2 hours)."
We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. 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 home health services
(procedure code 99601) provided to the enrollee from March 26, 2021 to March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-
network (OON) provider on September 9, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on
September 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99349) rendered by an out-of-network
(OON) provider on May 17, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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.
You are not a network provider with the Plan. The Plan had network providers available who could have
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the home visit (99349) rendered by an out-of-network (OON) provider on
May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided
from April 7, 2021, to April 22, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you were
charged twice, and you were not released from the hospital. 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 $185 per
day for days 1-5 and $0 per day after day 5 for each hospital stay. The contract also says that a transfer to a
separate facility type is considered a new admission.
The record shows you were transferred from acute inpatient to inpatient rehabilitation status on April 7, 2021.
This transfer is considered a new admission. Therefore, you have been asked to pay $185 per day for the first
five days of inpatient rehabilitation services. The total for this admission is $925 ($185 copayment x 5 days =
$925). Inpatient rehabilitation services fall 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 rehabilitation services provided from April 7, 2021, to April
22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient (99350) and the annual wellness visit (G0438) rendered by the out-of-network (OON)
provider on August 20, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the home visit for the evaluation and management of an established patient
(99350) and the annual wellness visit (G0438) rendered by the out-of-network (OON) provider on August 20,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the two x-rays you received on July 9,
2021.
You asked the Plan to waive the copayment for the two x-rays. You say that you already had to pay several
different copayments for this date of service, so you think the cost of the x-rays should be included in the
specialist visit cost sharing. The Plan denied your request. The Plan says you were charged these copayments
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 $15
copayment for each x-ray service.
You have been asked to pay a $15 copayment for each of the two x-rays. These copayments apply regardless of
what other services you may receive on the same date. 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
the two x-rays you received on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the spine you had on September 29, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you are retired with very little income
and would like this waived. The Plan denied your request. The Plan says you were charged this copayment
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180
copayment for advanced imaging services.
You have been asked to pay a $180 copayment for the MRI. The MRI falls within the advanced 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 the magnetic resonance
imaging (MRI) of the spine you had on September 29
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) and cast supplies (A4580) provided on
June 2, 2021.
You asked the Plan to pay for foot orthotics and cast supplies. You say that these items were medically
necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. Medicare rules state that code A4580 is not valid for
Medicare purposes and is not payable. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and did not wear a leg brace.
Although orthotics may be appropriate, neither Medicare nor the Plan provides coverage of orthotics for this
condition. Furthermore, code A4580 is not valid for Medicare purposes and is not payable. Therefore, we
decided that the Plan does not have to pay for foot orthotics (L3000) and cast supplies (A4580) provided on
June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Denosumab injection 1mg (J0897)
provided on March 23, 2021.
You asked the Plan to waive the coinsurance for a Denosumab injection. You say that the services should be
covered as you were unaware of the charges, and it would change your decision on whether you will continue
receiving them. The Plan denied your request. The Plan says the coinsurance applied correctly based on the
services provided.
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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for a Denosumab injection 1mg (the allowed amount is
$4,391.80, 20% of that is $878.36). Denosumab injections fall 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 a Denosumab injection 1mg
(J0897) provided on March 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on March 16, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you paid this bill in full to protect your credit. You are requesting reimbursement of the expenses you paid. The Plan denied your request. The Plan says it has sent you a check for the allowed amount of the ambulance services minus your applicable $165 copayment.
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 $165 copayment for ambulance services. You have been asked to pay a $165 copayment for the ambulance services. This copayment was subtracted from the amount that the Plan reimbursed you for these ambulance services. This was appropriately subtracted 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 you received on March 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography scan (70450) provided on July 26,
2021.
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
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 the computed tomography scan (70450) provided
on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the neurology visit you had on May 3,
2021.
You asked the Plan to waive the copayment for the neurology visit. You say that you believe this may be a
coordination of benefits issue. The Plan denied your request. The Plan says you were charged this copayment
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for services with a specialist.
You have been asked to pay a $35 copayment for the neurology visit. The neurology visit falls within the
services with a specialist 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 the
neurology visit you had on May 3, 2021
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the Continuous positive airway pressure (cpap) device provided on June 3, 2021.
You asked the Plan to pay for the cpap device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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 provided no documentation verifying that the provider is not enrolled in the Medicare program. The Plan did not provide enough information to confirm if the provider is not enrolled in the Medicare program. Therefore, we decided that the Plan has to pay for the Continuous positive airway pressure (cpap) device provided on June 3, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services (J7620) provided on July 16, 2021.
You asked the Plan to pay for code J7620. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code J7620 has a status indicator of M and the claim submitted denied for OCE 72 per Medicare payment guidelines. The Plan states they will accept a corrected claim for payment reconsideration for all claim lines. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services (J7620) provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on March 24, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 out of network services provided to the enrollee on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on July 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like reconsideration because you had an
accident and are not able to travel back to Florida due to COVID. The Plan denied your request. The Plan says
prior authorization is required for out-of-network services.

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 (99203) provided on July 21, 2021
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 21, 2021,
through August 24, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an
inpatient admission was not medically necessary. The request is appropriate at the observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found that the record showed that at the time of inpatient admission the admitting physician
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from August 21, 2021, through August 24, 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.