Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized foot and advanced knee. 
 
You asked the Plan to pre-approve a computerized foot and advanced knee. You say that the items are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 a computerized foot and advanced 
knee. Our reviewer says that the items are not medically necessary. Our physician reviewer found provided 
medical records do not document trial and failure of an advanced mechanical knee and foot or document why 
an advanced mechanical knee and foot would not meet the enrollee's needs.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a computerized foot and advanced knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized foot and advanced knee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided October 11, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that a clinicians rationale for the definitive testing 
and the tests ordered must be documented in the patients medical record. 
 
We looked at the file and Medicare rules. Insufficient records were provided to support the billed service. No 
clinical records were provided. The only records provided for review were lab results. 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 drug testing (G0483) provided October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 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. The rules say that procedure codes 80320 to 80377 are non-covered by 
Medicare. 
 
We looked at the file and Medicare rules. The services at issue are billed with procedure codes listed between 
80320 to 80377. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered 
on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 3, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for post-operative services is included in the 
global surgical package.  
 
We looked at the file and Medicare rules. The file shows that the enrollee underwent a surgical procedure billed 
with code 10061 (incision and drainage of abscess) on February 28, 2021. The services billed with code 10160 
(puncture aspiration of abscess) was performed within the 10-day global surgical period for the services on 
February 28, 2021. Payment for code 10160 is included in the global surgical package. Therefore, we decided 
that the Plan does not have to pay for the surgical services rendered on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00731) provided June 5, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says an explanation of benefits from the primary insurer is needed before 
the claim can be processed. 
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the anesthesia services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for anesthesia services (00731) provided June 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 28, 2020. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan 
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network 
provider, and the services were 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 the laboratory services provided on June 23, 2021, 
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided July 17, 2020. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 83789 is not supported in the medical record. Specifically, the records do not show that 
this is a distinct service from CPT codes G0480 and 80307. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (83789) provided July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on September 15, 2021. 
 
You asked the Plan to pay for these services. You say that you understood the services would be covered as 
preventive care. The Plan denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on September 15, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 at the current level of function, the enrollee's rehabilitation can be safely 
provided at a lower intensity and alternate setting in a skilled nursing facility. Documentation does not support 
the necessity for admission to an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services (procedure code 74177) provided 
to the enrollee on March 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 74177 is "Computed tomography, abdomen and pelvis; 
with contrast material(s)." 
 
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 not supported by the medical records. Our reviewer found a review of the records showed a 
single scan of the abdomen and pelvis conducted on March 15, 2021. No second exam is in the records. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services (procedure code 74177) provided to the enrollee on March 15, 
2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance service, advanced life support, non-emergency transport 
(A0426), and ground mileage (A0425) provided on November 5, 2021. 
 
You asked the Plan to pay for the transportation services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the transportation services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 transportation services. Our reviewer 
says that the transportation services were medically necessary. Our physician reviewer found the provided 
documentation did support that the enrollee needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport on November 5, 2021. The 
reviewer also found that the documentation did support that the ambulance transport on November 5, 2021 was 
medically reasonable and necessary for the enrollee. Therefore, the reviewer found that the transportation 
services in this case 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 transportation services have been met. Therefore, we decided that the Plan 
has to pay for the ambulance service, advanced life support, non-emergency transport (A0426), and ground 
mileage (A0425) provided on November 5, 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 waive the copayment for the office visit (99213) provided on 
December 14, 2021. 
 
You asked the Plan to waive 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 service 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 $50 
copayment for a specialist office visit.  
 
You have been asked to pay a $50 copayment for the specialist office visit 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 waive the copayment for the office visit (99213) provided on  
December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
23, 2020, to May 27, 2020. 
 
 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 the provider has reported inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was admitted and treated for pneumonia and pulmonary edema seen 
on on computed tomography (CT) scan. The laboratory results showed kidney function was near baseline, and 
there was no hypotension or other instability noted to meet Sepsis 3 criteria. There was no signs of organ 
dysfunction directly related to the infection, and therefore, there was insufficient support made in the provided 
documentation for DRG 871. DRG 193 (SIMPLE PNEUMONIA AND PLEURISY WITH MCC), therefore, is 
more appropriate according to the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 23, 2020, to May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on September 22, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says the hearing 
benefit is not covered if the services are not ordered through the Plan's designated hearing vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through the Plans network hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the 
Plans network hearing provider. Based on this information, we decided that the Plan's rules for coverage of 
hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing 
aids provided on September 22, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional imaging services (procedure codes 77066, G0279) provided 
to the enrollee on March 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 77066: 
 
Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 
 
Healthcare Common Procedure Coding System (HCPCS) G0279: 
 
Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) 
 
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 the enrollee had bilateral diagnostic 
mammography, CPT 77066 and bilateral CPT G0279 on 3/22/21. Computer aided detection was also used and 
documented. The report supports the use of this coded procedure. No duplicate charge or report is in the 
records. 
 
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 
additional imaging services (procedure codes 77066, G0279) provided to the enrollee on March 22, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the chemotherapy administration (96413) provided 
on February 9, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment as you had already met the out-of-pocket maximum for the calendar year at the time of 
service. The Plan denied your request. The Plan says that the coinsurance has been applied correctly to the 
service provided. 
 
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 documentation submitted by the Plan was not sufficient to be 
able to determine if you had met the maximum out-of-pocket amount by the time the service was rendered. The 
Explanation of Benefits statements submitted have conflicting information as to services being denied or 
applying cost share. In addition, we could not confirm the allowed amount for the service at issue since the 
Explanation of Benefits statement lists the same cost for the allowed amount and coinsurance applied. Since we 
could not determine if your maximum out-of-pocket had been met and we could not confirm the allowed 
amount of the service, we cannot determine if the coinsurance you are being asked to pay is correct. The Plan 
has not clearly substantiated their decision so we must find in your favor. Therefore, we decided that the Plan 
has to waive the coinsurance for the chemotherapy administration (96413) provided on February 9, 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.