Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation. The Plan 
denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on January 04, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you do not agree with 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 $10 for 
each covered visit or consultation in an outpatient location with your primary care provider (PCP) or other 
primary care provider. Covered services include: Consultation, diagnosis, and treatment by a specialist. 
 
You have been asked to pay a $10 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits 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 office visit on January 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kit purchased on January 25, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kit. You say that you would like to be reimbursed for 
this test per the policy dates you heard about. The Plan denied your request. The Plan says this test was 
purchased prior to the Plan's supplemental benefit went into place for COVID-19 home test kits. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The Plans 
contract also states that coverage for COVID-19 home test kits will not be provided for test kits purchased prior 
to February 1, 2022. Therefore, we decided that the Plan does not have to pay for the COVID-19 home test kit 
purchased on January 25, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for aortography and intravascular ultrasound provided to the enrollee on 
February 2, 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 that the records do not support the services billed. 
 
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 
of the denied codes is:  
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the aortogram was documented in the 
report, as was the intraluminal ultrasound images used for intervention. The latter procedure was documented 
with the images stored digitally. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
aortography and intravascular ultrasound provided to the enrollee on February 2, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on January 4, 
2022. 
 
You asked the Plan to pay for subsequent hospital care (99232). The Plan denied your request. The Plan says 
the claim remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for a MA plan begins while the enrollee 
is an inpatient, payment for inpatient services until the date of the enrollees discharge is made by the previous 
MA organization or original Medicare, as appropriate.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital care (99232) have not been met. Specifically, the enrollee was inpatient when 
the service was received. The payer responsible in the beginning of the admission is responsible for the full 
span of services. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) 
provided on January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray exams of the knee (73562-26-LT, 73562-26-RT) 
provided on February 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network x-rays. You say that the enrollee does not have a choice in what 
radiologist reads their diagnostic tests. The Plan denied your request. The Plan says out-of-network care is 
covered only in certain limited circumstances. The requested x-rays were not urgent or emergent, nor were they 
pre-approved. These services could have been received from an in-network provider. 
 
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 x-ray exams of the knee (73562-26-LT, 73562-26-
RT) provided on February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no documentation of conservative therapy such as topical 
antifungals, antibiotics or oral steroids. 
 
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 pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The record indicates 
that you have a diagnosis of unspecified panniculitis. The record provided is insufficient to establish that you 
have chromic intertrigo or functional impairment. Our physician reviewer found that your condition does not 
meet criteria for coverage of these services. 
 We looked at this physician's review, the file, and Medicare rules. 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 pre-approve panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted nervous system procedure (64999) provided on 
August 25, 2021. 
 
You asked the Plan to pay for the unlisted nervous system procedure (64999). You say that the anesthesia 
services provided meets all the criteria and you are requesting immediate payment. The Plan denied your 
request. The Plan says CPT code 64999 remains not supported as there is a more appropriate code for the 
service billed. 
 
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 64999 is unlisted procedure, nervous system. 
 
  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 unlisted nervous system procedure (64999). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the records submitted were insufficient to determine what service the unlisted procedure code is 
being reported for. 
 
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 unlisted nervous system procedure (64999) have not been met. Therefore, 
we decided that the Plan does not have to pay for the unlisted nervous system procedure (64999) provided on 
August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xhance nasal spray. 
 
You asked the Plan to pre-approve Xhance. The Plan denied your request. The Plan says this 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 Xhance nasal spray.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on February 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the cataract surgery. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
cataract surgery. We found no exception that would require the Plan to pay for the cataract surgery. The 
records provided for review do not show that the cataract surgery was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for cataract surgery provided on February 14, 2022, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital care provided from 
July 8, 2021, through July 12, 2021. 
 
You asked the Plan to reduce the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $275 
copayment per day, for days 1-5 and $0 after day 5, each time you are admitted to an acute care hospital. This 
applies to all admissions, including a transfer from another facility such as an acute rehabilitation or skilled 
nursing.   
 
 You have been asked to pay $1,100 ($275 copayment x 4 days) for the inpatient hospital care provided. 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 reduce the copayment for the inpatient hospital care provided from July 8, 2021, 
through July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on March 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that the enrollee does not go to your laboratory, so 
the enrollee is not using out-of-network benefits as his/her participating doctor sends you the specimen(s) to 
process. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The 
Plan also says that 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 pathology services provided on March 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on January 24, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied 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 $120 
copayment for an ultrasound.  
 
You have been asked to pay a $120 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 an ultrasound on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management (99443) provided 
on March 8, 2022. 
 
You asked the Plan to pay for the telephone evaluation and management (99443). You say that the attached 
chart notes support the prolonged services time spent and medical necessity. The Plan denied your request. The 
Plan says providers are required to use either location code 02 or location code 10 for telephone visits. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that use of the telehealth 
Place of Service (POS) Code 02 certifies that the service meets the telehealth requirements. 
 
  In this case, the CPT Code Manual definition of code 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion. 
 
We find that CPT code 99443 is not supported in the medical record. Specifically, the claim was not billed with 
the correct POS code. Based on this information, we decided that Medicare rules for coverage of the telephone 
evaluation and management (99443) have not been met. Therefore, we decided that the Plan does not have to 
pay for the telephone evaluation and management (99443) provided on March 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracorporeal photopheresis (36522) provided on March 
7, 2022. 
 
You asked the Plan to pay for the extracorporeal photopheresis. You say that continuing photopheresis should 
be considered medically necessary and covered for the enrollee. The Plan denied your request. The Plan says 
there was no documentation of a lung transplantation. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare also provides coverage for extracorporeal 
photopheresis for the treatment of bronchiolitis obliterans syndrome (BOS) following lung allograft 
transplantation. 
 
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 extracorporeal photopheresis. Our 
reviewer says that the enrollee did not meet the criteria for coverage. Our physician reviewer found the enrollee 
was diagnosed with bronchiolitis obliterans causing worsening dyspnea requiring steroids, Rituximab and 
oxygen support along with ongoing Cyclosporine, Cytoxan, and inhalers. Photopheresis was requested. Our 
reviewer found that the provided records did not clearly show a documented lung transplant to meet Medicare 
criteria. Our physician reviewer also found that there was no approved indication found in the documentation 
considering this fact nor any other indication supported by high quality evidence to support this request at this 
time. 
 
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 extracorporeal photopheresis have not been met. Therefore, we decided that 
the Plan does not have to pay for the extracorporeal photopheresis (36522) provided on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the inpatient hospital admission provided 
from November 30, 2021, to December 4, 2021. 
 
You asked the Plan to waive the deductible for the inpatient admission. You say that you have never been 
responsible for a deductible and feel you should only be responsible for your $300 copayment for these 
services. The Plan denied your request. The Plan says this claim was processed correctly, and your share of the 
cost was assessed in accordance with your contract. 
 
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 $250 deductible which applies to inpatient hospital stays. The contract 
also states that after this deductible is met, you pay $300 per calendar year for covered services received in a 
general acute care hospital (inpatient hospital care). 
 
The item or service you asked the Plan to waive the deductible for falls within the inpatient hospital stays 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 
deductible which applies to inpatient hospital stays. This cost sharing is a contractual obligation that had not 
been met at the time the inpatient admission was received on November 30, 2021 to December 4, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for the inpatient hospital admission 
provided from November 30, 2021, to December 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (codes 85060 and 88342) provided on 
December 1, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not 
billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that no separate payment is made for code 85060. 
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 88342 is a column II code to column I code 
88189. 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
testing (codes 85060 and 88342) provided on December 1, 2021.