Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 
2 hours) (CPT code 99601) and home infusion/specialty drug administration, per visit (up to 2 hours); each 
additional hour (List separately in addition to code for primary procedure) (CPT code 99602) provided to the 
enrollee on March 3, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code(s): 99601 and 99602 have a status code "I". Medicare guidance says status code ?I? Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. 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 infusion/specialty drug administration, per visit (up to 2 
hours) (CPT code 99601) and home infusion/specialty drug administration, per visit (up to 2 hours); each 
additional hour (List separately in addition to code for primary procedure) (CPT code 99602) provided to the 
enrollee on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on February 11, 2021.

You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable without a modifier.

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 71045 is a column II code to column I code 71046. 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 an x-ray (71045) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TAVR procedure (CPT code (s): 33361 and 33362) to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee needs to have TAVR 
procedure at this provider for continuity of care as they are already receiving cardiology care at this facility for 
chronic thromboembolic pulmonary hypertension. The Plan denied your request. The Plan says there was no 
preauthorization from the provider on file. The Plan states there is no referral from a contracted network 
provider, and it is the responsibility of the provider and the enrollee to check coverage and benefits prior to 
rendering or receiving services. The Plan states the enrollee scheduled the TAVR procedure with full 
knowledge that the provider is out-of-network. The Plan states the clinical documentation provided reflects that 
the services provided are non-emergent in nature and there are in-network providers available that could have 
provided the services rendered. 
 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 
TAVR procedure (CPT code (s): 33361 and 33362) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for raised toilet seat (CPT code E0244), general use wheelchair 
seat cushion, width less than 22 inches, any depth (CPT code E2601), lightweight wheelchair (CPT code 
K0003) and sales tax (CPT code S9999) purchased February 6, 2021, from a non-certified for Medicare. 
 
You asked the Plan to pay for the items. You say that you cannot go to the Plan's medical supply companies 
without the wheelchair. The Plan denied your request. The Plan says this provider is not certified with 
Medicare. 
 
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 rules say that to receive payment for covered Medicare items or services from either Medicare (in the case 
of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier 
must be enrolled in the Medicare program. Furthermore, Medicare does not reimburse separately for sales tax. 
Therefore, we decided that the Plan does not have to pay for raised toilet seat (CPT code E0244), general use 
wheelchair seat cushion, width less than 22 inches, any depth (CPT code E2601), lightweight wheelchair (CPT 
code K0003) and sales tax (CPT code S9999) purchased February 6, 2021, from a non-certified for Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from February 25, 2021, to March 4, 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 there was a DRG procedure code error.

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 diagnosis code. 

We looked at the file and Medicare rules. The claim was billed for a procedure (08Q9XZZ Repair Left Cornea, External Approach) that is statutorily not covered based on Medicare guidelines. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from February 25, 2021, to March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiology office visit you had on May 
21, 2021. 
 
You asked the Plan to waive the copayment for the cardiology office visit. You say that you disagree with this 
copayment. 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 visits with a specialist.  
 
You have been asked to pay a $35 copayment for the cardiology office visit. The cardiology office visit falls 
within the visits 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 cardiology office visit you had on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the epidural steroid injection procedure you 
had at an ambulatory surgery center on April 9, 2021. 
 
You asked the Plan to waive the copayment for the epidural steroid injection procedure. You say that you had 
this procedure before with another doctor and only had to pay $40. 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 $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for the epidural steroid injection procedure. The epidural 
steroid injection procedure 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 the epidural steroid injection procedure you had at an ambulatory surgery center on 
April 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home therapy, irrigation therapy (e.g., sterile irrigation of an 
organ or anatomical cavity); including administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem 
(CPT code S9590) provided to the enrollee on January 12, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this service is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 CPT code S9590 has a status code "I". Medicare guidance says status code ?I? Not valid for Medicare 
purposes. Medicare uses another code for reporting of and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we 
decided that the Plan does not have to pay for home therapy, irrigation therapy (e.g., sterile irrigation of an 
organ or anatomical cavity); including administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem 
(CPT code S9590) provided to the enrollee on January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization with Tetanus-Diphtheria vaccine provided on 
May 4, 2021. 
 
You asked the Plan to pay for Tetanus-Diphtheria vaccine. You say that the provider gave you the booster 
without telling you it would not be covered under your medical benefit. The Plan denied your request. The Plan 
says rules for payment have not been met. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus-Diphtheria 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus-Diphtheria 
vaccine. Therefore, we decided that the Plan does not have to pay for immunization with Tetanus-Diphtheria 
vaccine provided on May 4, 2021.  
 
Benefits for Tetanus-Diphtheria vaccine 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: Favorable

We decided that the Plan has to pay for urgent care services received on January 8, 2021.

You asked the Plan to pay for the services. You say that you fell and injured your shoulder while on the job. The Plan denied your request. The Plan says that the charges were never submitted to the worker's compensation insurance carrier for processing.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The plan has not met its obligation to coordinate benefits with the primary insurer. The plan has only contacted the provider's billing department, and confirmed that the charges were never submitted to worker's compensation for processing. The plan has provided no direct evidence that the provider will be submitting the claim to worker's compensation for processing, or that the plan directed the provider to send the bill to the primary insurer. There are no call logs to substantiate the plan's denial. The plan has not itself sent the bill to the primary carrier for processing. 

Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for urgent care services received on January 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hearing aid, not otherwise classified (V5298) purchased 
May 19, 2021 from an out of network provider. 
 
You asked the Plan to pay for the hearing aids. You say that your Plan includes hearing aid coverage and you 
believe you should have been reimbursed for the purchase of the device. The Plan denied your request. The 
Plan says enrollee's must receive hearing services from an in network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. Hearing aids are 
covered when purchased from the designated in-network vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the Hearing aid, not otherwise classified (V5298) purchased May 19, 2021 from an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply (CPT code A9276).

You asked the Plan to pre-approve the sensor. You say that you need the sensor approved because it goes with your insulin pump to help control your diabetes and you said if you do not have the sensors for your insulin pump then you cannot control your diabetes. The Plan denied your request. The Plan says this request is for a sensor that is for a non-therapeutic glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Specifically, this request is for a sensor that is for a non-therapeutic glucose monitor. This request is for a sensor that is for a non-therapeutic glucose monitor. Therefore, we decided that the Plan does not have to pre-approve sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply (CPT code A9276).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from August 4, 2020 to 
August 18, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the medical records support DRG 853 
with principal diagnosis code A41.9 and secondary diagnosis code N17.0. The Plan denied your request. The 
Plan says the medical records do not support DRG 853 with principal diagnosis code A41.9 and secondary 
diagnosis code N17.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9:  Sepsis, unspecified organism. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that the 
medical records do not support DRG 853 with principal diagnosis code A41.9 and secondary diagnosis code 
N17.0. Our physician reviewer found the enrollee was transferred to the facility from another facility for 
treatment of osteomyelitis. No submitted documentation indicated a systemic, life-threatening organ 
dysfunction due to a dysregulated host response to infection, which defines sepsis. Wound cultures reflected a 
localized infection. No urine cultures were performed by the billing facility. The enrollee remained alert and 
oriented throughout inpatient admission and required no oxygen support. No sustained documented signs of 
hypotension with MAP less than 65. In addition, there were no reported hepatic, respiratory, cardiologic, renal 
or neurological dysfunctions manifested. On exam, lungs clear bilaterally, non-toxic appearing. Platelets-246, T 
Bili-0.6, Lactic acid-1.3.  The enrollee's presentation warranted consideration of sepsis; however, after 
adequate fluid resuscitation and IV antibiotics, lab values promptly reflected improvement. There was no 
evidence of significant physiologic instability due to infection. Medical record received and available for 
review does not support condition treated as consistent with systemic infectious process. The initial creatinine 
of 1.3, the serum creatinine level stabilized at 0.7-0.8 after adequate hydration. The review has determined that 
the medical records did not support DRG 853 with principal diagnosis code A41.9 and secondary diagnosis 
code N17.0.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from August 4, 2020 to August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on April 5, 2021. 
 
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 procedure code 99233 is 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 99233 is Level 3 subsequent hospital care for evaluation 
and management of patient, including detailed physical examination and medical decision making of moderate 
complexity, typical time 35 minutes. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, there is no documentation of 
evaluation and management notes to support that Level 3 subsequent hospital care was performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care rendered on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for airway inhalation treatment services received on June 7, 2021.
 
You asked the Plan to waive the copayment for the services. You say that you were told that this would be 
covered. The Plan denied your request. The Plan says the copayment was applied correctly, as you have not 
met the out-of-pocket maximum. 
 
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 $25 
copayment for pulmonary rehabilitation services.  
 
You have been asked to pay $12.25 for the services. The services fall within the pulmonary rehabilitation services benefit category. Normally, the copayment is $25, but the allowed amount was less than the copayment amount. 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 airway inhalation treatment services received on June 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) 
procedure you had at an ambulatory surgery center on January 13, 2020. 
 
You asked the Plan to waive the copayment for the EGD procedure. You say that you did not have this 
procedure on this date. 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 $225 
copayment for surgery or other services in an ambulatory surgery center.  
 
We reviewed the medical records for this service. The medical records confirm that you received this procedure 
on January 13, 2020. You have been asked to pay a $225 copayment for the EGD procedure. The EGD procedure falls within the surgery or other services in an ambulatory surgery center 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 esophagogastroduodenoscopy (EGD) procedure you had 
at an ambulatory surgery center on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7953) received on April 13, 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 there is no supplemental benefit that would apply to cover this service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services (D7953) received 
on April 13, 2021.