Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic care provided on October 03, 
2022, to November 02, 2022. 
 
You asked the Plan to waive the copayment for chiropractic care. 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 a $20 
copayment for chiropractic services. 
 
You have been asked to pay a $20 copayment for chiropractic care. This item/service falls within the 
chiropractic 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. The total amount you are being asked to pay is $120 ($20 x 6 visits = $120). Therefore, we decided 
that the Plan does not have to waive the copayment for chiropractic care provided on October 03, 2022, to 
November 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99291, 93010) provided on April 6, 
2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed codes are not separately payable. 
 
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 codes 99291, & 93010 are not supported in the medical record. Specifically, codes 99291 
and 93010 are included in the global surgery package of code 12002 which was also billed for the same date of 
service. Based on this information, we decided that Medicare rules for coverage of the physician services have 
not been met. Therefore, we decided that the Plan does not have to pay for physician services (99291, 93010) 
provided on April 6, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from December 20, 2022, to 
February 7, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that your primary care provider encouraged you to see a 
Licensed Marriage and Family Therapist to deal with the emotional and physical stress of caring for your wife 
who has Parkinsons Disease. You say that you would think this provider who is trained and experienced 
would be as qualified and likely more qualified than most doctors, nurse practitioners or physician assistants to 
provide the type of care you need. The Plan denied your request. The Plan says Medicare does not consider 
Licensed Marriage and Family Therapist to be eligible providers at this time.  
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
 We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from December 20, 2022, 
to February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three units of procedure code 87801 rendered on April 11, 
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 a Healthcare Common Procedure Coding System/Current Procedural Terminology 
(HCPCS/CPT) code shall be reported only if all services described by the code are performed. 
 
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 87801 is "Infectious agent detection by nucleic acid 
(DNA or RNA), multiple organisms; amplified probe(s) technique." 
 
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 enrollee had a urinary tract 
infection who had pathogenic DNA testing for coagulase negative staph. The documentation does not support 
that three units of 87801 were tested in this case. 
 
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 three units of procedure code 87801 rendered on April 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound services provided on February 
9, 2023. 
 
You asked the Plan to waive the copayment for ultrasound services. You say that you are being billed twice for 
the same service. The Plan denied your request. The Plan says the cost sharing will be applied according to the 
Plan contract. 
 
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 $25 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay two $25 copayments for ultrasound services. The Plan contract specifies that this 
copayment applies to each service rendered. These items/services fall 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 
ultrasound services provided on February 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracapsular cataract removal and posterior chamber 
intraocular lens provided on January 19, 2023. 
 
You asked the Plan to pay for extracapsular cataract removal and posterior chamber intraocular lens. You say 
that this service is supported in the records. 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 extracapsular cataract 
removal and posterior chamber intraocular lens provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 06, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. 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 home visit provided 
on March 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64491 and 77002 billed for date of service 
July 26, 2022. 
 
You asked the Plan to pay for procedure codes 64491 and 77002. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 codes 
64491 and 77002 are add-on codes and have not been billed with an appropriate primary procedure code. 
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 codes 64491 and 77002 billed for date of service July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 872 rendered 
from October 20, 2022, to October 30, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
requesting reconsideration. The Plan denied your request. The Plan says septicemia or severe sepsis was 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 DRG 872. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was admitted and treated with fluids and empiric antibiotics. Ear, nose, throat (ENT) doctor 
did not believe surgical sites were infected. Urinalysis and blood cultures were normal. It was noted that the 
enrollee had the influenza vaccine 2 days prior. There was no source of infection identified, and the enrollee 
was stable. He did not meet Sepsis 3 criteria. The documentation for this admission does not support diagnosis 
code A41.9 - sepsis, unspecified organism, and therefore, the DRG 607 is more appropriate.  
 
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 reported with DRG 872 rendered from October 20, 2022, to October 30, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 99292, 93005, and 93041 for date of service February 1, 2023.

You asked the Plan to pay for procedure codes 99292, 93005, and 93041. 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.

We find that CPT codes 99292, 93005, and 93041 are not payable as billed. Specifically, codes 93005 and 93041 have a status indicator of Q1. Procedure code 99291 was billed on the same claim, with the same date of service, with a revenue code of 450. According to the I/OCE Quarterly Release Files, this gives CPT code 99291 a status indicator of "S". Therefore, the payment for CPT codes 93005 and 93041 is included in the payment for CPT code 99291 and they are not separately payable. In addition, CPT 99292 has a status indicator of "N". Codes with a status indicator of "N" are never separately payable. Based on this information, we decided that Medicare rules for coverage of procedure codes 99292, 93005, and 93041 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99292, 93005, and 93041 for date of service February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2310) for an approved power 
wheelchair. 
 
You asked the Plan to pre-approve an electronic connection. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
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 an electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records document the enrollee has 4/5 to 5/5 upper extremity (wrist/grip) 
strength and is "largely independent" with upper body dressing and grooming, indicating that the enrollee has 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2310) for an approved power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
December 13, 2022, to December 16, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. 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 a $175 
copayment for outpatient hospital services/lab services. 
 
You have been asked to pay a $175 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/lab 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, you are only being asked to pay $83.10 for one date of service 
(DOS) and $111.85 for the third DOS which is less than the required amount. The total amount you are being 
asked to pay is $369.95 ($175 + $111.85 + $83.10 = $369.95). Therefore, we decided that the Plan does not 
have to waive the copayment for outpatient hospital services provided on December 13, 2022, to December 16, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, malignant lesion including margins and repair, 
complex, forehead provided on January 24, 2023, to January 26, 2023. 
 
You asked the Plan to pay for excision, malignant lesion including margins and repair, complex, forehead. You 
say that the services were medically necessary. 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 excision, malignant 
lesion including margins and repair, complex, forehead provided on January 24, 2023, to January 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that this is medically necessary for the enrollee. 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 Mounjaro.   
Benefits for Mounjaro 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (72125, 72128, 70450 and 99283) 
provided on November 16, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the service was paid by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary insurer has paid the Medicare allowable amount. As the secondary insurer, the Plan cannot be 
held responsible for the emergency room services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for emergency room services (72125, 72128, 
70450 and 99283) provided on November 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (90471, 90715, 99283) provided 
on November 6, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the primary payer is responsible for payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary insurer has paid the claim at more than the Medicare allowable rate. As the secondary insurer, 
the Plan cannot be held responsible for the emergency room services until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for emergency room services 
(90471, 90715, 99283) provided on November 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96521 and 99214 rendered on January 5, 
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 the denied codes are not supported in the records submitted. 
 
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 96521: 
 
Refilling and maintenance of portable pump 
 CPT 99214: 
 
Office or other outpatient 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 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
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 in terms of CPT 96521, the 
medical record does not include documentation of refilling and maintenance of portable pump. Additionally, 
the records do not include any documentation of an evaluation and management procedure. The records include 
a progressive infusion flow sheet, and instructions for appointments. Therefore, CPT 99214 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 96521 and 99214 rendered on January 5, 2023.