Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
September 7, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that you expect 30% 
payment from the billed charges per the contract. You say that documents required to reprocess the underpaid 
claim are attached. The Plan denied your request. The Plan says CPT codes 99350 and 97597 had been paid 
and CPT code 99072 remains denied as bundled services are not eligible for separate payment. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine and associated administration charges 
for date of service September 9, 2021. 
 
You asked the Plan to pay for the Shingles vaccine. You say that this vaccine was given to the patient in the 
clinic on September 9, 2021. The Plan denied your request. The Plan says this vaccine is not covered under the 
patient's medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that the patient has been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine and associated 
administration charges for date of service September 9, 2021.  
 
Benefits for the Shingles 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: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on July 8, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the claim for the surgeon 
was paid but this claim was denied as not medically necessary. You say that this should have been paid and the 
claim should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not 
eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
  We find that CPT code 99100 is not supported in the medical record. Specifically, Specifically, CPT code 
99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the special anesthesia 
service (99100) have not been met. Therefore, we decided that the Plan does not have to pay for the special 
anesthesia service (99100) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on December 17, 
2021. 
 
You asked the Plan to waive the copayment for wound care. You say that you were charged $40 for your first 
visit, and the charges for this visit are too high. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per date of service for outpatient surgery services provided in an outpatient hospital facility setting.  
 
You have been asked to pay $186.01 for wound care, which is less than your $350 copayment. Wound care 
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers, benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for wound care provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xyosted. 
 
You asked the Plan to pre-approve Xyosted. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
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 pre-approve Xyosted.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to appeal the authorization 
denial of the claim. The Plan denied your request. The Plan says you must get approval in advance from your 
in-network primary care physician (PCP). 
 
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from September 3, 2021, to September 14, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the copayment should be waived 
since the service you received was horrible. 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 $20 
copayment per day for days 1-20 of a benefit period for a skilled nursing facility stay. The contract also says 
that there a $0 copayment for days 21-100 of a benefit period. 
 You have been asked to pay a total of $240, which is a $20 copayment per day for a 12 day SNF stay ($20 
copayment x 12 days = $240). A SNF stay falls within the Skilled Nursing Facility (SNF) Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay provided 
from September 3, 2021, to September 14, 2021.  
 
Your complaint about the staff being rude and the bad food is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for intravenous (IV) therapy provided on November 4, 
2021. 
 
You asked the Plan to waive the copayment for IV therapy. You say that you did not have IV therapy. The Plan 
denied your request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 medical records to confirm what services were 
performed. Without the medical records we are unable to confirm what services were rendered and determine if 
the cost share applied is correct. Therefore, we decided that the Plan has to waive the copayment for 
intravenous (IV) therapy provided on November 4, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight wheelchair and automated lift provided on 
September 15, 2021. 
 
You asked the Plan to pay for the lightweight wheelchair and automated lift. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider you 
received these items from is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the lightweight wheelchair and 
automated lift provided on September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pain pump infusion services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pain pump infusion services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says there are in-
network providers available to render this service. 
 
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 
the pain pump infusion services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided October 12, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you feel that you would not have been 
billed if you had been in your home state when the ambulance services were provided. The Plan denied your 
request. The Plan says ambulance services are not covered when there is no transport.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 12, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for inpatient physician services provided from 
November 23, 2021, to November 24, 2021. 
 
You asked the Plan to waive the deductible for inpatient physician services. You say that you had already met 
your deductible for 2021. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to inpatient hospital care.  
 
The record shows your deductible was met with the processing of this claim. The inpatient physician services 
you asked the Plan to waive the deductible for falls within the Inpatient Hospital Care benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which 
applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time 
inpatient physician services was received on November 23, 2021, to November 24, 2021. Therefore, we decided that the Plan does not have to waive the deductible for inpatient physician services provided from 
November 23, 2021, to November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), sphere, bifocal, plano to plus or minus 
4.00d, per lens (V2200), vision item or service, miscellaneous (V2799), and unlisted special service, procedure 
or report (99199) provided on June 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames, lenses, miscellaneous vision item and unlisted special service. You 
say that you were told you could submit a claim for reimbursement. The Plan denied your request. The Plan 
says the eyewear is not covered because it was provided OON. 
 
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 frames (V2020), sphere, bifocal, plano to plus 
or minus 4.00d, per lens (V2200), vision item or service, miscellaneous (V2799), and unlisted special service, 
procedure or report (99199) provided on June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81003 billed for date of service December 
16, 2021. 
 You asked the Plan to pay for procedure code 81003. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says it has decided to pay for code 81001 billed on this date of 
service.  However, the Plan says that payment for code 81003 is bundled into payment for code 81001. 
 
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 81003 
is a column II code to column I code 81001. 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 81003 billed for date of service December 16, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on July 15, 
2020. 
 
You asked the Plan to pay for the subsequent hospital care (99232). You say that CPT code 99232 is falling 
within the global period of code 28825. You say that the records prove the service billed was medically 
necessary and the claim should be processed for payment. The Plan denied your request. The Plan says the 
corrected claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
  The record shows that the corrected claim for the subsequent hospital care (99232) was not filed until 
November 30, 2021. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on July 3, 2021. 
  You asked the Plan to pay for the CT scan. You say that the attached medical records support the service, and 
the claim should be reprocessed for payment. The Plan denied your request. The Plan says an appropriate 
modifier was not billed with this code edit. 
 
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 CT scan provided on July 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
November 1, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that the reimbursement 
was reduced well below the amount billed and you demand immediate payment of 30% of the billed charges. 
The Plan denied your request. The Plan says bundled services are not eligible for separate payment. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a non-participating neurosurgeon. 
  You asked the Plan to pre-approve an office visit with a non-participating neurosurgeon. You say that you 
would like a follow up with the out-of-network provider. The Plan denied your request. The Plan says a list of 
in-network neurosurgeons was provided for your request. Therefore, they could not authorize an out-of-
network neurosurgeon. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 an office visit with a non-participating neurosurgeon. Our reviewer says 
that you do not meet the criteria for treatment with the requested out-of-network provider. Our physician 
reviewer found the record indicates that you have cerebral aneurysm and there is not a sign that any acute or 
emergent intervention is necessary. The record does not indicate that the Plan is unable to provide this service. 
The record shows that there are in-network providers available to provide the needed services. Out-of-network 
treatment is not medically reasonable or 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 an office visit with a non-participating neurosurgeon have not been met.  
 
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 an office visit with a non-participating neurosurgeon. 
Therefore, we decided that the Plan does not have to pre-approve an office visit with a non-participating 
neurosurgeon.