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

 
We decided that the Plan has to pay for the lab services provided on July 21, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the billed units 
are not supported. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided on July 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 pay for procedure code 99349-25 rendered on July 24, 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 there was no significantly, separately identifiable evaluation and management (E&M) service 
identified in the documentation sent with the appeal. 
 
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 99349 is "Home or residence visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 40 minutes must be met or exceeded." 
 
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 that  99349 is not supported. The 
record does not support that a separately reportable evaluation and management service was provided along 
with the wound care. 
 
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 procedure code 99349-25 rendered on July 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient diagnostic test provided on 
June 23, 2023. 
 
You asked the Plan to waive the coinsurance for an outpatient diagnostic test. You say that you disagree with 
the copayment. 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 20% 
coinsurance for outpatient diagnostic tests/Medicare-covered diagnostic radiology. 
 
You have been asked to pay 20% coinsurance for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered diagnostic radiology 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 coinsurance for an outpatient diagnostic test provided on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(recline, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with single power option. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says there is not a medical need 
for the requested power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when the coverage criteria are met. 
 
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 Group 3 power wheelchair with single 
power option. Our reviewer says that the requested Group 3 power wheelchair with single power option is not 
medically necessary. Our physician reviewer found the provided documentation indicates the enrollee does not 
have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means 
of managing power drive. Therefore, the reviewer found that the requested Group 3 power wheelchair with 
single power option is not medically reasonable or 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 Group 3 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single 
power option (recline, seat elevator) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99233 billed for date of service March 28, 2023. 
 
You asked the Plan to pay for 99233. You say that 99233 should be paid as billed because the enrollee was 
either seen by both a mental health provider and a physician, or they were transferred for subsequent/other care. 
The Plan denied your request. The Plan says 99233 is denied because documentation was not received for this 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that in order for another E&M service to be paid on the 
same calender date as critical care services, the documentation must support that the other E&M visit was 
provided prior to the critical care services, that the services were medically necessary, and that the services 
were separate and distinct with no duplicative elements from the critical care services provided later in the day. 
 
We looked at the file and Medicare rules. In this case, we confirmed that 99233 was billed on the same 
calender day as critical care services described by code 99291 by a provider of the same billing group and 
specialty. We confirmed that modifier -25 was not appended to either code. While the case file contains copies 
of both claims, it does not contain any medical records for any of the services billed on March 28, 2023. Per 
Medicare rules, supporting documentation is required when determining if an E&M service billed on the same 
day as a critical care service is eligible for separate payment. Documentation would need to support that 99233 
was performed prior to the critical care services billed on the same day, that 99233 was medically necessary, 
and that 99233 was a separate and distinct service from the critical care services with no duplicative elements 
in order for separate payment to be allowed. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of 99233 have been met. Therefore, we 
decided that the Plan does not have to pay for the evaluation and management services described by code 
99233 billed for date of service March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on August 08, 
2023. 
 
You asked the Plan to pay for evaluation and management services. You say that medical records were 
provided. 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 evaluation and 
management services provided on August 08, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home skilled nursing visits. 
 
You asked the Plan to pre-approve the home skilled nursing visits. You say that the weekly nurse visitations are 
necessary for the management of the enrollee's medications. You also say that it is only because of the weekly 
nursing visits that the enrollee has been stable for the last few years. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home skilled nursing visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee is noted to be medically stable. They do not require wound care, catheterization, gastrostomy tube 
feeding, or administration of intravenous or complex medications. Our reviewer found that the enrollee has 
been educated regarding their medications and they have not recently been hospitalized. The enrollee is noted 
not to be homebound. Our physician reviewer also found that the enrollee is receiving home health skilled 
nursing care to ensure that they take their oral medications. This by itself does not require skilled nursing care 
and the administration of his medications are not complex enough to necessitate skilled nursing care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home skilled nursing visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve home skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aid or assistive listening 
device/supplies/accessories provided on July 13, 2023. 
 
You asked the Plan to reimburse you for hearing aid or assistive listening device/supplies/accessories. You say 
that you were told you would receive full reimbursement. The Plan denied your request. The Plan says hearing 
aid or assistive listening device/supplies/accessories are excluded from coverage. 
 
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.  
 
We looked at the file and the Plan's rules. The file shows that the Plan does not cover hearing aid accessories 
and supplies. Therefore, we decided that the Plan does not have to reimburse you for hearing aid or assistive 
listening device/supplies/accessories provided on July 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an eye injection provided on August 10, 
2023. 
 
You asked the Plan to waive the coinsurance for an eye injection. You say that you have been having these 
injections done for years and never had to pay this much. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an eye injection. This item/service falls within the Medicare 
Part B prescription drugs 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. The total you owe is $350.27 ($1,751.34 x 20% = $350.27). Therefore, we decided that the 
Plan does not have to waive the coinsurance for an eye injection provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the requested 
service is not appropriate for anyone over age 80. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must be under 80 years old to receive this 
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 transurethral waterjet ablation of the 
prostate. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has benign prostatic hyperplasia and lower urinary tract symptoms. The 
enrollee is over the 80 years of age and therefore the rule precludes the provision of this service as not 
medically reasonable and necessary as defined by Medicare rules. The elements of the coverage criteria are not 
satisfied. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of the prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service May 24, 
2023. 
 You asked the Plan to pay for procedure code 87801. The Plan denied your request. The Plan says payment for 
code 87801 is bundled into payment for code 87631. 
 
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 87801 
is a column II code to column I code 87631. 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 87801 billed for date of 
service May 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydrocortisone acetate powder. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has had no improvement with 
plain topicals and needs a compounded 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 hydrocortisone acetate 
powder.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing test provided on August 29, 
2023. 
 
You asked the Plan to waive the copayment for the hearing test. You say that you disagree with the additional 
copayment. 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 $15 
copayment for hearing services. 
 
You have been asked to pay a $15 copayment for the hearing test. This item/service falls within the hearing 
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 copayment for the hearing test provided 
on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the electrocardiogram provided on July 
26, 2023, by an OON provider.  
 You asked the Plan to pay for the office visit and electrocardiogram. You say that you have submitted 
supporting documentation to support the billed charges. The Plan denied your request. The Plan says these 
services are not covered when received by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan has a POS option to use either network providers or out-of-network providers for certain covered services. 
The contract also says that out-of-network outpatient diagnostic tests and physician services are not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
items/services 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 office visit and the electrocardiogram provided 
on July 26, 2023, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on July 22, 
2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you disagree with the $75 
copayment. 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 $125 
copayment for ambulance services. 
 
You have been asked to pay a $125 copayment for an ambulance ride. This item/service falls within the 
ambulance 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. However, since the allowed amount is less than the standard copayment, you only owe $75. 
Therefore, we decided that the Plan does not have to waive the copayment for an ambulance ride provided on 
July 22, 2023.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says based on the records, the enrollee would not be able to tolerate three hours 
of therapy daily, five days a week  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services performed from December 6, 2022, 
through December 15, 2022. 
 
You asked the Plan to pay for the dialysis services. You say that the dialysis services should be paid as billed 
because they were medically necessary. The Plan denied your request. The Plan says the dialysis services are 
denied because the required condition code 84 was not included on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that AKI claims are billed with condition code 84. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the primary diagnosis assigned was 
N17.9, defined as acute renal failure, unspecified. As N17.9 is a non-ESRD code and there is no diagnosis assigned to indicate ESRD, the AKI dialysis rules would apply. AKI claims must be billed with condition code 
84. We have confirmed that the submitted claim does not include documentation of condition code 84. As such, 
the denial of the dialysis services is appropriate. Based on this information, we decided that Medicare rules for 
coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay 
for the dialysis services performed from December 6, 2022, through December 15, 2022.