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

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on February 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 CPT 99285 is not eligible for 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. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the notes from this encounter in 
the emergency department describes elevated glucose and hallucinations, but no other appropriate history was 
provided to describe the context and extent of the symptoms and recent clinical history. Also, it was noted that 
the enrollee was alert and awake; however, there was no formal or appropriate physical examination 
documented. The enrollee was treated with Ativan. The documentation did not sufficiently support a medically 
appropriate history or examination and did not sufficiently support a high level of medical decision making.  
 
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 emergency room services (procedure code 99285) rendered on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27093 and 73525 rendered on July 19, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has been informed that the service was billed incorrectly. 
 
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 27093: 
 
Injection procedure for hip arthrography; without anesthesia 
 CPT 73525: 
 
Radiologic examination, hip, arthrography, radiological supervision and interpretation 
 
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 the procedure report describes a 
cortisone injection in bilateral hip with radiological guidance. In this case, there is a more appropriate code to 
report for a hip injection. In this case, CPT 27093 cannot be verified. Additionally, the documentation does not 
describe a hip examination. Therefore, there is a more appropriate code to report than CPT 73525. This code 
cannot be verified. 
 
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 codes 27093 and 73525 rendered on July 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service January 6, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plans denial. The 
Plan denied your request. The Plan says the services billed are 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 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 
documentation does not support the code billed. Our reviewer found the enrollee presented with a headache and 
complaints that his blood pressure was high. The enrollee was diagnosed with accelerated hypertension and a 
headache. The documentation supports an appropriate exam, but not an appropriate history or medical decision 
making of high level. Therefore, 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 for date of service January 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the EGD and diagnostic colonoscopy 
provided on January 12, 2023. 
 
You asked the Plan to waive the cost share for the EGD and diagnostic colonoscopy. You say that since this 
was ordered in 2022 when you had already met your deductible you want this reprocessed without any cost 
share. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to in-network outpatient surgery. Your 
contract with the Plan also says that you must pay 5% coinsurance after meeting the deductible for in-network 
or out-of-network outpatient surgery. 
 
 You have been asked to pay $420.01 towards the deductible for the EGD. You have also been asked to pay 
$172.53 towards the deductible for the diagnostic colonoscopy. The items or services you asked the Plan to 
waive the cost share for fall within the outpatient surgery benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $750 deductible which applies to in-network outpatient 
surgery. This cost sharing is a contractual obligation that had not been met at the time the EGD and diagnostic 
colonoscopy was received on January 12, 2023.  
 
You have also been asked to pay $33.66, which is less than the standard 5% coinsurance for the diagnostic 
colonoscopy. This item/service falls within the outpatient surgery 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 EGD and diagnostic colonoscopy provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology consultation to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a cardiology consultation. You say that this is medically necessary and 
should be covered. The Plan denied your request. The Plan says there are other providers available who are in-
network, who are within the Medicare allowable distance from your residence. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cardiology consultation to be provided by an out-of-network (OON) provider.
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 Group Therapeutic Procedures for admission to an 
inpatient rehabilitation facility is medically necessary for the enrollee. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for inpatient rehabilitation facility. Services needed may be provided 
safely in a lower level of care. 
 
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. 
 
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 office visit provided on April 19, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 the office visit provided 
on April 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network mammogram and bone 
density scan (DEXA) provided on November 14, 2022. 
 
You asked the Plan to waive the copayment for an in-network mammogram and bone density scan (DEXA). 
You say that this is preventative and should be covered in full. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for an in-network mammogram and bone density scan (DEXA). 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network mammogram and bone density 
scan (DEXA) provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and a compression 
sleeve to be provided by an OON provider.  
 
You asked the Plan to pre-approve a compression device and a compression sleeve. You say that you are 
requesting reconsideration of the denied items. The Plan denied your request. The Plan says the items were not 
approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device and a compression sleeve to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration.  The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 for date of service February 16, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
We find that CPT code 99291 is not payable as billed. Specifically, this code was billed with diagnosis codes 
J44.9 and J47.9. Due to an Excludes1 note, these two diagnosis codes should not be billed together. The claim 
is not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99291 for date of service February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on March 
20, 2023. 
 
You asked the Plan to waive the coinsurance for an aflibercept injection. You say that you do not want to be 
responsible for the cost sharing. 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 in-network Medicare Part B covered drugs provided at all locations of service. 
 
You have been asked to pay 20% coinsurance for an aflibercept injection. This item/service falls within the in-network Medicare Part B covered drugs provided at all locations of service 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 $366.52 
($1832.60 allowed amount x 20% = $366.52). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an aflibercept injection provided on March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81209, 81216, 81223, 81238, 81241, 81242, 
81249, 81250, 81279, 81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81339, and 81345 for date of 
service April 3, 2023. 
 
You asked the Plan to pay for procedure codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 
81279, 81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81339, and 81345. You say that you 
disagree with the plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed.  
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
 
We find that CPT codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 
81307, 81311, 81317, 81320, 81321, 81334, 81339, and 81345 are not payable as billed. Specifically, these 
services were billed with diagnosis codes D72.818 and D81.89. Due to an Excludes1 note, these diagnosis 
codes should not be billed together. The claim is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 
81250, 81279, 81298, 81305, 81307, 81311,  81317, 81320, 81321, 81334, 81339, and 81345 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 81209, 81216, 81223, 
81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81339, 
and 81345 for date of service April 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 23, 2022, to 
October 26, 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 you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the inpatient services are not 
payable as billed. 
 
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 N17.9, defined as acute kidney failure, unspecified. 
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 DRG billed is not supported. Our physician reviewer found the 
enrollee presented to the hospital with a urinary tract infection. Baseline creatinine was reported as 1.4 mg/dL. 
Creatinine in the ED was 1.65 mg/dL. The enrollee was treated with fluids and antibiotics. Repeat creatinine 
following fluids was 1.14, 1.16, and 1.10 mg/dL. Based on the provided documentation, the enrollee does not 
meet criteria for acute kidney failure as there was no evidence of anuria, a 1.5+ rise in creatinine beyond 
baseline or a creatinine rise of 0.3 mg/dL within 24 hours.   
 
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 October 23, 2022, to October 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 22, 2023, to 
April 19, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you were not aware this would not be 
covered. 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 the laboratory services 
provided on February 22, 2023, to April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided on August 04, 2021, to August 
05, 2021. 
 
You asked the Plan to pay for the hospital services. You say that the care followed well-established guidelines. 
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 the hospital services 
provided on August 04, 2021, to August 05, 2021.