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

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit specimen collection for severe 
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) (code C9803) 
provided on July 11, 2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit specimen collection for severe acute respiratory 
syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]). The Plan denied your request. The 
Plan says this code was billed in an inappropriate place 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, the CPT Code Manual definition of code C9803 is hospital outpatient clinic visit specimen 
collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), 
any specimen source.  
We find that CPT code C9803 is not supported in the medical record. Specifically this code is only payable on 
the Outpatient Prospective Payment System (OPPS) which must be billed on an institutional claim. Based on 
this information, we decided that Medicare rules for coverage of hospital outpatient clinic visit specimen 
collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease  
[COVID-19]) have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 
(coronavirus disease [COVID-19]) (code C9803) provided on July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 49905 provided on April 2, 2022. 
 
You asked the Plan to pay for the medical services coded 49905. You say that this procedure is supported in the 
documentation submitted. The Plan denied your request. The Plan says the code billed is not supported in the 
medical records submitted. 
 
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 49905 is omental flap, intra-abdominal (List separately in 
addition to code for primary procedure). 
 
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 medical services coded 49905. Our reviewer says that the 
documentation does not support payment for the CPT code as billed. Our reviewer found that in this case the 
operative report does not include documentation of an intra-abdominal omental flap per National Correct Coding Initiative (NCCI) Policy: The physician mobilizes an omental flap for reconstruction of a defect. The 
surgical recipient site of the flap is prepared. An upper abdominal transverse or midline incision is made. A 
laparotomy and manual exploration of the abdominal cavity is done first and the omentum and transverse colon 
are delivered from the cavity. The omentum is dissected from the transverse colon from left to right and small 
vessels are ligated. When completely separated from the transverse colon, the omentum is dissected from the 
stomach with careful clamping, division, and ligation of vessels. The omentum is fully mobilized and pedicled 
on the right or left gastroepiploic vessel, depending on the purpose. More incisions and tunnWeling may be 
necessary to bring the flap into its new location to fill a defect. The flap may be used as a pedicled transposition 
flap or a free microvascular transfer flap.  Operative report describes a graham patch for peritoneal free air and 
reported with other specified disorders of peritoneum.  In this case, there is a more appropriate code to report 
for this service. 
 
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 medical services coded 49905 have not been met. Therefore, we decided 
that the Plan does not have to pay for the medical services coded 49905 provided on April 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 4, 2022, to May 3, 
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 NOA was not submitted correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The admit date is in 2021. For enrollees receiving services in 2021 that continue into 2022, the home health 
agency must submit a Notice of Admission (NOA) with a one-time artificial "admission" date corresponding 
the "from" date of the first period of continuing care in 2022. 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 provided from April 4, 2022, to May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the cost share for office visits provided on September 24, 2021, to 
October 29, 2021. 
 
You asked the Plan to waive the cost share for office visits. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says that the cost-sharing amount you are being charged is correct. 
 
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 did not provide an complete Explanation of Coverage (EOC). Without 
this information we are unable to determine if the cost sharing amount was applied correctly. Therefore, we 
decided that the Plan has to waive the cost share for office visits provided on September 24, 2021, to October 
29, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 2, 2022, to July 
1, 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 the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 2, 2022. The NOA was not received by the Plan until January 8, 2021. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
June 2, 2022, to July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity prostheses and supplies. 
 You asked the Plan to pre-approve lower extremity prostheses and supplies. 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 lower limb prostheses are covered when specific 
criteria are met. 
 
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 lower extremity prostheses and 
supplies. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
current prostheses are 3 years old. There is no evidence of change in function requiring new prostheses. A 
change in socket does not require a new prothesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity prostheses and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lower extremity prostheses and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one way non-emergency transportation 
(A0100). 
 
You asked the Plan to pre-approve additional one way non-emergency transportation (A0100). You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says the member is allowed 
a total of 20 one-way trips for the benefit year. The Plan also says that the member is requesting more than 20 
trips total. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one way non-emergency transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from July 7, 2022, to  
August 11, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the Plan 
requires prior authorization for coverage of an out-of-network provider. The Plan allows for out-of-network 
coverage for emergency 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 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 physician's services provided from July 7, 2022, to 
August 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional non-emergency one-way transportation 
trips. 
 
You asked the Plan to pre-approve the non-emergency one-way transportation trips. You say that the additional 
trips are medically necessary. The Plan denied your request. The Plan says you have had 14 round trip visits 
and one extra visit for a total of 29 one-way trips covered for your medical needs. The Plan says they may 
cover up to 60 one-way trips. You still have 31 one-way trips to use before December 31, 2022. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.   
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency one-way transportation trips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 27, 2022, to 
May 20, 2022. 
 
You asked the Plan to pay for the home health services. 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 claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that the denied claim was submitted 
with an admission date of March 28, 2021, which is not the same admission date submitted on the NOA. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from April 27, 
2022, to May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that Entyvio is medically necessary. The Plan denied your 
request. The Plan says a trial of Inflectra or Avsola is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Entyvio. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found the record does not a show a trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the hospital on 
April 25, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs are not Part B covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
in the hospital on April 25, 2022.  
 Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glucerna oral nutritional supplement. 
 
You asked the Plan to pre-approve Glucerna oral nutritional supplement. You say that you are a diabetic and 
Glucerna helps with your blood as you have to take this oral supplement twice a day. The Plan denied your 
request. The Plan says Medicare does not cover nutritional supplements. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Glucerna oral nutritional supplement.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary. The Plan 
denied your request. The Plan says skilled therapy is no longer required. 
 
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 the therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are not medically necessary. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for home health. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service is available from a provider in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for home health.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that your condition is not controlled. The Plan 
denied your request. The Plan says you do not meet criteria for a continuous glucose monitor. 
 
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 you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (37253, 99152, J3360, Q9967) provided 
on May 3, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 30, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (37253, 99152, J3360, Q9967) 
provided on May 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service August 9, 2022. 
 
You asked the Plan to pay for code 99284. You say that the patient was seen twice on the same day. The Plan 
denied your request. The Plan says payment for code 99284 is bundled into payment for code 99291. 
 
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 99284 
is a column II code to column I code 99291 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 code 99284 billed for date of service August 9, 2022.