Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on October 13, 2021. You asked the Plan to pay for the eyeglasses. You say that you called the Plan before making this purchase and 
were told that you could be reimbursed for these services. The Plan denied your request. The Plan says routine 
vision services are only covered when they are received from a provider in the Plan's specified routine vision 
vendor network. The provider in this case is out-of-network, and the Plan was unable to locate a call from you 
to customer service before the date in question. 
 
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 they are received from a provider in the Plans vision vendor 
network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified network. 
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravenous tubing extension set (S1015) billed for date of 
service October 13, 2021. 
 
You asked the Plan to pay for an intravenous tubing extension set. You say that the requested item was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S1015 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT code S1015 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of an intravenous tubing extension set have not been met. Therefore, we decided that the Plan does 
not have to pay for an intravenous tubing extension set (S1015) billed for date of service October 13, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the rhythm electrocardiogram (ECG) interpretation and report rendered 
on April 21, 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 that procedure code 93042 is not separately payable. 
 
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 states that code 93042 is a column II code with a modifier indicator of 
1 when billed with column I code 99291; however, there are no active National Correct Coding Initiative 
(NCCI) procedure-to-procedure (PTP) edits for these codes. The Plan has not provided any documentation or 
Medicare rules to support that the services are not payable as billed. Therefore, we decided that the Plan has to 
pay for the rhythm electrocardiogram (ECG) interpretation and report rendered on April 21, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from October 22, 2021, to October 24, 
2021. 
 
You asked the Plan to pay for the inpatient stay. You say that the inpatient stay was medically necessary at the 
acute level of care. The Plan denied your request. The Plan says that the inpatient stay was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient stay. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier emergency department and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient stay have been met. Therefore, we decided that the Plan has to pay 
for the inpatient stay provided from October 22, 2021, to October 24, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 21, 
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 you refused transport to the hospital. 
 
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 January 21, 2022. 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 ambulance services provided to the enrollee on 
January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 14, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are unable to reach the patient for her to 
contact the referring, or previous primary care provider for referral information, and she will not return your 
calls. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and 
they have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 laboratory services provided on September 14, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy (31625-59) provided on December 1, 
2021. 
 
You asked the Plan to pay for the bronchoscopy. You say that these services are unbundled and 31625 should 
be paid separately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 31625 and 31628. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. Code 31625 was billed with modifier -59 to bypass 
the edit; however, a review does not support that the criteria for use of this modifier are met. 
 
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 31625 is a column II code to column I code 31628; however, 31625 
was billed with a modifier.  
 
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 bronchoscopy. Our reviewer says that use of the -59 
modifier is not supported in this case. Our reviewer found the procedure report does not support that these 
services were performed at different anatomical sites or a different patient encounter; therefore, modifier -59 
cannot be verified. 
 
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 bronchoscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for the bronchoscopy (31625-59) provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on December 2, 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 99100 is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. 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 special 
anesthesia service rendered on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex arterial scan and office visit rendered on August 
14, 2021 to August 15, 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 the claim is a duplicate. 
 
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. 
 We looked at the file and Medicare rules. The file shows that the code 93880 was previously paid by the Plan 
on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met.  
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 99215 and 99205. Code 99215 is a column II code with a 
modifier indicator of 1 when billed with column I code 99205. Code 99215 was not billed with an appropriate 
modifier to allow for separate payment. 
 
Therefore, we decided that the Plan does not have to pay for the duplex arterial scan and office visit rendered 
on August 14, 2021 to August 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. You do not require 
skilled therapy services due to severe cognitive deficits, hallucinations and non-compliance preventing benefit 
from therapy. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not document that services in the long-term care facility on a part time basis (if you can participate 
in the future) are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (CPT Code G0483) provided November 24, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the test was ordered by a treating physician who 
makes the professional determination of diagnosis and medical necessity to successfully treat their patients. 
The Plan denied your request. The Plan says documentation does not support the services were medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 drug testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the diagnosis is medication management of long 
term (current) drug therapy. The medical record sent by the provider shows a definitive UDT panel for multiple 
drug classes was performed but does not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. The review has determined that the 
documentation does not support the services were 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive urine drug testing (UDT) for 22 or more drug classes (CPT Code G0483) provided 
November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve an inpatient psychiatric hospitalization. The Plan denied your request. The 
Plan says the clinical documentation provided and reviewed does not show an impending threat to self or 
others. The Plan also says that the evidence supported that the enrollee's clinical condition improved, and he 
was no longer at imminent danger to himself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
  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 inpatient psychiatric hospitalization. 
Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care 
beyond the date in question of March 25, 2022. Our physician reviewer found it is not expected this enrollee 
will improve in a reasonable period of time as he was not showing any dangerousness to self or others, no 
auditory or visual hallucinations, and no aggressive behaviors. The enrollee was compliant and cooperative 
with treatment. Our reviewer also found that it does not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
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 inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the orbit/ear/fossa 
rendered on January 9, 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 services are 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 CPT code. In this case, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the orbit/ear/fossa 
rendered on January 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided to the enrollee on 
November 3, 2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says the claim 
has been adjusted to retract payment. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided to the enrollee on November 3, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDx-Melanoma testing (81529) provided on May 3, 2021. 
 
You asked the Plan to pay for the DecisionDX-Melanoma testing. You say that you would like reconsideration 
because this testing is a Medicare covered benefit. The Plan denied your request. The Plan has not addressed 
the appellants argument for coverage.   
 
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. Specifically, the Plan has not forwarded any evidence to indicate why this 
service was denied. The Plan has not provided the original denial or any Medicare citations to validate their 
decision. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for the DecisionDx-Melanoma testing (81529) provided on May 3, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered on August 15, 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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99053 is not separately payable. 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 medical 
services rendered on August 15, 2021.