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

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service 
December 20, 2022. 
 
You asked the Plan to pay for procedure codes 87899 and 87900. You say that these services were necessary 
and were reported appropriately. The Plan denied your request. The Plan says these codes are not supported in 
the medical record. 
 
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 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 procedure codes 87899 and 87900. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found the record does not contain results or 
documentation showing that detection by immunoassay with direct optical observation (87899) or drug 
susceptibility phenotype prediction using updated genotypic informatics (87900) were performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87899 and 87900 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service December 20, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found continuation of the home ventilator is not 
medically necessary. There is no documentation of failure of bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. The plan has approved the home ventilator 
for 3 months to allow time for transition to BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the items/services provided from 
November 11, 2022, to January 30, 2023. 
 You asked the Plan to waive the copayments for the items/services. You say that you feel you are being 
overcharged. The Plan denied your request. The Plan says this cost sharing was charged 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 2022 contract with the Plan clearly says that you must pay a 
$45 copayment for specialist office visits. Your 2022 contract with the Plan also clearly says that you must pay 
a $25 copayment for each outpatient diagnostic test. Your 2022 contract with the Plan also clearly says that you 
must pay a $275 copayment for each outpatient diagnostic radiology service.  
 
Your 2023 Contract with the Plan clearly says that you must pay a $45 copayment for each specialist office 
visit. 
 
Date of Service CPT Code Allowed Amount Copayment 
November 11, 2022 99204 $180.48 $45 
November 11, 2022 93015 $78.26 $25 
December 6, 2022 93306 $223.90 $25 
December 8, 2022 93268 $206.85 $25 
December 13, 2022 78452 $512.11 $275 
December 13, 2022 99212 $61.69 $45 
December 13, 2022 93015 $78.26 $25 
January 16, 2023 99212 $61.69 $45 
January 30, 2023 99442 $96.80 $45 
Total $555 
 
You have been asked to pay a $45 copayment for each specialist office visit provided in 2022. You have also 
been asked to pay a $45 copayment for each specialist office visit provided in 2023. This item/service falls 
within the physician/practitioner services benefit category. You have also been asked to pay a $25 copayment 
for each diagnostic procedure and test. You have also been asked to pay a $275 copayment for each outpatient 
diagnostic radiology service. These items/services fall within the outpatient diagnostic tests and therapeutic 
services 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 copayments for the items/services 
provided from November 11, 2022, to January 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the observation services, occupational 
therapy services, drug injections, and medical supplies provided from September 12, 2022, to September 13, 
2022. 
 You asked the Plan to waive the cost share for the observation services, occupational therapy services, drug 
injections, and medical supplies. You say that the charges are excessive. The Plan denied your request. The 
Plan says this cost sharing was charged 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 $360 
copayment for in-network outpatient hospital observation services. Your contract with the Plan also clearly 
says that you must pay a $40 copayment for each in-network outpatient occupational therapy service. 
 
Your contract with the Plan also clearly says that you must pay 20% coinsurance for in-network Medicare Part 
B drugs. Your contract with the Plan also clearly says that you must pay 20% coinsurance for in-network 
medical supplies. 
 
You have been asked to pay a $360 copayment for the observation services. This item/service falls within the 
outpatient hospital observation benefit category. You have also been asked to pay a $40 copayment for the 
occupational therapy services. This item/service falls within the outpatient rehabilitation services benefit 
category.  
 
You have also been asked to pay 20% coinsurance for each drug injection. This item/service falls within the 
Medicare Part B drugs benefit category. You have also been asked to pay 20% coinsurance for each medical 
supply. This item/service falls within the outpatient diagnostic tests and therapeutic services 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 cost share for the observation services, occupational therapy services, drug 
injections, and medical supplies provided from September 12, 2022, to September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 20, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 20, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
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 inpatient psychiatric care from June 20, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of June 20, 2023, forward. Our physician reviewer found 
the enrollee did not require inpatient mental health treatment beyond June 20, 2023, as he was not a danger to 
himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 20, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 20, 2023, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
March 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified preventive procedure (D1999) provided on March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional computed tomography (CT) scan rendered on 
January 12, 2023. 
 
You asked the Plan to pay for the services. You say that the claim was denied as duplicate in error. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 24, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for an additional computed tomography (CT) scan rendered on 
January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum assisted suspension system (VASS) (L5981). 
 
You asked the Plan to pre-approve a VASS. You say that there is no appropriate alternative to flexible keel foot 
with a hydraulic ankle that will meet the enrollee's functional needs. The Plan denied your request. The Plan 
says that there are not enough studies to show vacuum socket is safe and effective for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 VASS. Our reviewer says that the 
requested VASS is considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided medical record is sufficient to justify the requested suspension system. The reviewer also found 
that though Medicare policy is technically non-specific about coverage rules for VASS, it does in fact routinely 
cover it, meaning it cannot be on its face experimental. The reviewer also found that this system is in the 
mainstream of standards of prosthetic care. Therefore, the reviewer found that the requested VASS is medically 
reasonable and 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 a VASS have been met. Therefore, we decided that the Plan has to pre-approve 
a vacuum assisted suspension system (VASS) (L5981).  
 
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 procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by a network doctor. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023, to February 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 16, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77012 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 77012. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 77012 is bundled into payment for code 
76942. 
 
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 77012 
is a column II code to column I code 76942. 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 77012 billed for date of service September 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99153) provided on October 11, 2022. 
 
You asked the Plan to pay for the sedation services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional 
component / technical component indicator of 3 and is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that 
the Plan does not have to pay for sedation services (99153) provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit services provided on June 2, 2022. 
 
You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the claim should be submitted first to the 
primary payer. 
 
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. In this case, the Plan provided no documentation verifying the enrollee was 
enrolled in a different Plan for the June 2, 2022, date of service. Our records show that the enrollee enrolled 
with this Plan (H1977) on April 1, 2022, which shows the enrollee was enrolled with this Plan on June 2, 2022. 
The Plan has provided no documentation that states otherwise. Therefore, we decided that the Plan has to pay 
for the office visit services provided on June 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 26, 2022, to August 31, 2022. 
 
You asked the Plan to pay for the SNF services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say the number of days of care charged to a beneficiary for 
inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days. A part of a day, 
including the day of admission and day on which a patient returns from leave of absence, counts as a full day. 
However, the day of discharge, death, or a day on which a patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of admission. 
 
We looked at the file and Medicare rules. The claim submitted for payment shows that the discharge day of 
August 31, 2022, was counted towards SNF inpatient days incorrectly. The units billed were more than the 
length of the stay. Based on this information, we decided that Medicare rules for coverage of the SNF services 
have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility 
(SNF) services provided from August 26, 2022, to August 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided from June 03, 2022, to 
March 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for mental health services. You say that you have been established with this provider 
for a long time, and you refuse to see anyone else. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 mental health services provided from June 03, 
2022, to March 2, 2023, by an out-of-network (OON) provider.