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

 
We decided that the Plan does not have to pay for the laboratory testing provided on October 11, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory testing provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that both of your feet are inverting into one another, 
and your Podiatrist said Orthotics will help with this issue. You're in a lot of pain daily and cannot walk. 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. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) for eyeglasses after cataract 
surgery. 
 You asked the Plan to pre-approve the evaluation and management service. You say that you just want your 
medical glasses after cataract surgery. The Plan denied your request. The Plan says you have previously 
received one pair of post cataract surgery glasses already. The Plan also says that the benefit has been 
exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The service you asked the Plan to pre-approve has certain limits. The record shows that the Plan paid for one 
pair of post cataract surgery glasses that you received on April 21, 2022. Therefore, we decided that the Plan 
does not have to pre-approve an office visit (99203) for eyeglasses after cataract surgery.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the comprehensive preventive evaluation (99387) 
provided on March 15, 2022. 
 
You asked the Plan to hold you harmless for the evaluation and management service. You say that you were 
seen for a routine pap-smear and mammogram. You also say that both services should be covered under your 
preventive health. The Plan denied your request. The Plan says that the claim processed correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The evaluation and management service was performed by a contract provider. The file does not show that the 
Plan provided notice that the evaluation and management service would not be covered. Under Medicare rules, 
this means the evaluation and management service is considered approved by the Plan. Therefore, we decided 
that the Plan has to hold you harmless for the comprehensive preventive evaluation (99387) provided on March 
15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 97110, 97530, 97535, and 97537 provided from 
December 1, 2021, to December 29, 2021. 
 
You asked the Plan to pay for codes 97110, 97530, 97535, and 97537. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 The CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact 
(use of dynamic activities to improve functional performance), each 15 minutes. 
 
The CPT Code Manual definition of code 97535 is self-care/home management training (eg, activities of daily 
living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of 
assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes. 
 
The CPT Code Manual definition of code 97537 is community/work reintegration training (eg, shopping, 
transportation, money management, avocational activities and/or work environment/modification analysis, 
work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 
minutes. 
 
We find that CPT codes 97110, 97530, 97535, and 97537 are not supported in the medical record. Specifically, 
the documentation submitted does not indicate that a total of 15 minutes was spent providing this therapy 
service on these dates of service. This means code 97110 is not supported by the documentation. 
 
The documentation submitted does not indicate that a total of 15 minutes was spent providing this therapy 
service on these dates of service. This means code 97530 is not supported by the documentation. 
 
The documentation submitted does not indicate that a total of 15 minutes was spent providing this Self-
care/home management training service on these dates of service. This means code 97535 is not supported by 
the documentation. 
 
The documentation submitted does not indicate that a total of 15 minutes was spent providing this therapy 
service on these dates of service. This means code 97537 is not supported by the documentation. 
 
Based on this information, we decided that Medicare rules for coverage of codes 97110, 97530, 97535, and 
97537 have not been met. Therefore, we decided that the Plan does not have to pay for codes 97110, 97530, 
97535, and 97537 provided from December 1, 2021, to December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refraction and any necessary prescription of lenses (92015) 
provided on June 1, 2022.  
You asked the Plan to pay for refraction and any necessary prescription of lenses. You say that refractive 
services are covered under your benefit plan. The Plan denied your request. The Plan says refractive services 
are not covered under your benefit plan unless rendered by an in-network provider and with a routine vision 
exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed by an in-network care provider, and during a routine 
exam. 
 
We looked at the file and the Plan's rules. The record shows that this service was not done during a routine 
examination, but during a medical examination. Based on this information, we decided that the Plan's rules for 
coverage of refraction and any necessary prescription of lenses have not been met. Therefore, we decided that 
the Plan does not have to pay for refraction and any necessary prescription of lenses (92015) provided on June 
1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0416 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the professional 
interpretation must be billed with modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code G0416 is surgical pathology, gross and microscopic 
examinations, for prostate needle biopsy, any method. 
 
We find that CPT code G0416 has a PC/TC indicator of 1. The claim information does not show that the code 
was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0416 billed for date of service March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of a new patient (99204) provided on May 10, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the providers have 
different specialties. The Plan denied your request. The Plan says the claim processed 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. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the record. Specifically, the documentation submitted 
indicates that this enrollee previously received professional services from a physician with the same specialty 
and billing group within the last 3 years. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
office or other outpatient visit for the evaluation and management of a new patient (99204) provided on May 
10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 24 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 51.6 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service October 19, 
2021. 
 You asked the Plan to pay for procedure code A4550. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code A4550 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH care is 
correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital or at a skilled nursing facility. The enrollee has improved and can receive further 
care at the current acute care hospital, or at a lower level of care when deemed appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health care. You say that you are appealing this supporting records. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested 
additional home health care. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer 
found the clinical documentation does not show any medical changes or concerns other than weakness and 
functional impairments, thus there is no reason why the continued assessment of a professional nurse would be 
required. 9 additional skilled nursing visits 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 home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 9 additional home health skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service May 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a golimumab injection and infusion 
provided on May 23, 2022 
 
You asked the Plan to waive the coinsurance for a golimumab injection and infusion. You say that you cannot 
afford to pay this. The Plan denied your request. The Plan says the cost share has been applied 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 a 30-day supply of insulin covered under Medicare Part B for use with an insulin pump; 20% 
coinsurance of the total cost for all other Medicare Part B drugs, including chemotherapy drugs.  
 
You have been asked to pay $488.40 for a golimumab injection and infusion. A golimumab injection and 
infusion 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 golimumab injection and infusion provided on May 23, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95886 billed for date of service December 
13, 2021. 
 
You asked the Plan to pay for the billed services. You say that the test identifies induced neurophysiological 
alterations. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). 
 
We find that CPT codes 95886 and 95886-XU are not supported in the medical record. The records provided 
do not include 4 units of a complete needle electromyography. The medical records provided do not show that 
the service billed with the -XU modifier is a distinct procedural service. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95886 billed for date of service December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on February 11, 
2022, to February 16, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
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 $340 
copayment per day for days 1-4 for each stay. $0 copayment per day for days 5-365 for each stay. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. The day 
before you are discharged is your last inpatient day. There were 5 days, but only being charged for days 1-4. 
$340 x 4 = $1,360. Therefore, results in the total cost sharing amount of $1,360.  
 
 
 You have been asked to pay a $340 copayment each day for days 1-4 of inpatient hospital stay. Inpatient 
hospital stay falls 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 hospital stay on February 11, 2022, to February 16, 2022.