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

 
We decided that the Plan does not have to pay for the wound supplies provided on July 31, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the wound supplies. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the items rendered are not covered when provided by an OON 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 the wound supplies provided on July 31, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on June 19, 2023. 
 
You asked the Plan to reimburse you for the hearing aids. You say that hearing aids are medically necessary. 
The Plan denied your request. The Plan says the provider you used is not in the Plan's network. 
 
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 provided by the Plans hearing care provider. 
 
We looked at the file, and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing care provider. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on June 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on May 15, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
procedure code 99285.  The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99285.  
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 code 99285. Our reviewer says that the medical records do not support the billing of procedure code 99285.  Our reviewer found based on the documentation 
provided, the enrollee was evaluated in the emergency department for back and leg pain. A cursory history and 
appropriate physical were documented. The medical decision making was not of high complexity. As such, the 
billing of CPT code 99285 is not supported. 
 
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 code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on May 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 6, 2023 
to February 8, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that fasdfasd 
The Plan denied your request. The Plan says the billed DRG is not supported. 
 
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 diagnosis code J96.01. 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 hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code J96.01 is not supported by the records provided. Our physician 
reviewer found that the enrollee presented with shortness of breath. She was treated for possible pneumonia 
and heart failure/fluid overload. While the enrollee was mildly hypoxic on presentation, there is no evidence 
that the enrollee was in respiratory failure. As such, the billing of diagnosis code J96.01 is not supported.  
 
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 the inpatient hospital services provided on February 6, 2023 to February 8, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve a myocardial perfusion imaging. The Plan denied your request. The Plan 
says based on Medicare guidelines, the Myocardial perfusion imaging (78452) requested does not meet the 
requirements for approval. 
 
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 a myocardial perfusion imaging. Our 
physician reviewer found this patient has no cardiac or pulmonary symptoms. There is no documentation that 
the electrocardiogram (ECG) shows an uninterpretable pattern. Our reviewer found that there is no evidence 
provided that would support the need for radionuclide stress testing. Our physician reviewer also found in 
summary, there is insufficient documentation to support the medical necessity for the requested cardiac stress 
testing in this patients clinical management. 
 
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 myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a myocardial perfusion imaging (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that the service at issue was a necessity for the enrollees 
care. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the 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 Ozempic.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mastectomy bra provided on June 30, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the mastectomy bra. You say that the other provider didn't answer the phone. The 
Plan denied your request. The Plan says this provider is out-of-network. 
 
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 item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the mastectomy bra provided on June 30, 2023, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets all conditions for 
approval of an LTACH admission. The Plan denied your request. The Plan says the clinical documentation 
does not show the enrollee needs continued treatment of a primary condition and no active management or 
treatment of at least two comorbid conditions. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with treatment but is not appropriate for 
LTACH care. The enrollee requires only short-term additional acute care services that can safely be provided at the current facility until more appropriate for transfer to a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to the 
LTACH is not medically necessary as it would not be clinically advantageous at this time. Completion of 
treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical eye examination and evaluation (92014, 92134) and 
intravitreal injection of a pharmacologic agent (67028) provided on September 11, 2023. 
 
You asked the Plan to pay for medical eye examination and evaluation (92014, 92134) and intravitreal injection 
of a pharmacologic agent (67028). You say that the coding is correct and medical records supports the services 
billed The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered.  
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for medical eye examination 
and evaluation (92014, 92134) and intravitreal injection of a pharmacologic agent (67028) provided on 
September 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on May 17, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on May 17, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services billed with codes A0431 and A0436 for date of 
service April 21, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that these air ambulance services were 
medically necessary. The Plan denied your request. The Plan says that the code billed is no longer valid. 
 
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. We find that the Plan has failed to supply adequate information regarding its 
denial rationale for this service. Specifically, the Plan's sole rationale for denial in this case is that the 'code 
billed is no longer valid.' However, multiple codes were billed on this claim, and the Plan failed to identify 
which code (or codes) it believes is invalid.  Further, the Plan has failed to provide a citation upon which this 
denial rationale is based. Rather, the Plan just provided a copy of an entire chapter of the Medicare Claims 
Processing Manual without pointing to a specific reference that supports its assertion that one of the codes 
billed is no longer valid. The burden is on the Plan to show why its denial was correct. By failing to identify 
which, if any, codes are actually invalid, and by failing to provide a specific citation to a rule upon which this 
code's invalidity is based, we find that the Plan has not met this burden. Therefore, we decided that the Plan has 
to pay for ambulance services billed with codes A0431 and A0436 for date of service April 21, 2023.  
 
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 a hospital outpatient clinic visit provided 
on August 02, 2023. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you disagree with 
the facility charge. 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 $245 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $245 copayment for a hospital outpatient clinic visit. This item/service falls 
within the outpatient hospital observation 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. However, since the allowed amount is less than the standard copayment, 
you only owe $130.53. Therefore, we decided that the Plan does not have to waive the copayment for a hospital 
outpatient clinic visit provided on August 02, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 22850-51-58-XS rendered on June 12, 2023. 
 
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 procedure code 22850-51-58-XS is considered inclusive to CPT 22840. 
 
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 22850 is "Removal of posterior nonsegmental instrumentation (eg, Harrington rod)." 
 
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 documentation does support CPT 
22850 as a separate and distinct procedure from CPT 22840: posterior non-segmental instrumentation (e.g., 
Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, 
sublaminar wiring at C1, facet screw fixation). The enrollee was being treated for spondylosis with 
radiculopathy of the lumbar region. The enrollee underwent an L3-4 posterior lumbar interbody fusion on 
6/12/23. The procedure details cite incision was made. The prior instrumentation was identified and the screw 
caps were removed as well as the rods. This procedure was performed prior to the instrumentation at L3-4, and, 
the removal of previous hardware was to allow for the primary procedure. 
 
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 
procedure code 22850-51-58-XS rendered on June 12, 2023.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 27, 2022, to 
May 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of J10.00 (influenza due to 
other identified influenza virus with unspecified type of pneumonia). 
 
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 diagnosis code J10.00 defined as influenza due to 
other identified influenza virus with unspecified type of pneumonia. 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 hospital services at the DRG originally billed. Our physician 
reviewer found that the provided documentation included chest x-ray findings negative for signs of pneumonia, 
effusion, or consolidation, and the patient had normal breath sounds on examination. Therefore, there was 
insufficient support of the patient having the diagnosis of pneumonia. Therefore, code J10.00 (Influenza due to 
other identified influenza virus with unspecified type of pneumonia) is not supported.  
 
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 on April 27, 2022, to May 2, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90999 billed for dates of service July 3, 
2023, to July 28, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the correct data 
was not submitted on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was not billed with a payable value code and amount. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 90999 billed for dates of 
service July 3, 2023, to July 28, 2023.