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

 
We decided that the Plan does not have to pay for the dialysis services described by codes 90999 and J1644 
billed from April 4, 2023, to April 7, 2023. 
 
You asked the Plan to pay for the dialysis services. You say that the dialysis services should be paid as billed 
because they are supported in the documentation and were medically necessary. The Plan denied your request. 
The Plan says the dialysis services are denied because the claim was not billed with one of the required 
principal diagnosis codes. 
 The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. The rules also say that hospital-based and independent renal facilities must assign a principal 
diagnosis of end stage renal disease for enrollees with ESRD. 
 
We looked at the file and Medicare rules. In this case, the records indicate the enrollee was diagnosed with and 
received dialysis for ESRD. We have confirmed that the principal diagnosis assigned on the claim was E11.22, 
defined as type 2 diabetes mellitus with diabetic chronic kidney disease. This diagnosis code does not indicate 
ESRD as required, so it is not a valid principal diagnosis code in this case. Per Medicare rules, the principal 
diagnosis for ESRD dialysis claims must be ESRD. 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 described by codes 90999 and J1644 billed from April 4, 2023, to April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient surgery provided on July 
10, 2023, to September 18, 2023. 
 
You asked the Plan to waive the copayment for each outpatient surgery. You say that there was no surgery. 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 $350 
copayment for surgery services provided at an outpatient hospital. 
 
You have been asked to pay a $350 copayment for each outpatient surgery. This item/service falls within the 
surgery services provided at an outpatient hospital 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 owe is $700 ($350 copayment x 2 services 
= $700). Therefore, we decided that the Plan does not have to waive the copayment for each outpatient surgery 
provided on July 10, 2023, to September 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin graft surgery provided on May 26, 2022. 
 
You asked the Plan to pay for the skin graft surgery. You say that you did not know the provider was out-of-
network, so you do not feel you should have to pay the billed amount. 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 skin graft surgery 
provided on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on August 22, 2023, to September 22, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 durable medical equipment (DME) provided on August 22, 2023, to September 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment purchased on May 5, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you are asking for review of your claim for 
reimbursement for a portable oxygen concentrator. The Plan denied your request. The Plan says the purchased 
oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for oxygen equipment 
purchased on May 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy billed for date of service June 13, 
2023. 
 You asked the Plan to pay for the billed item. You say that supporting documentation was provided. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records provided do not show that the enrollee is being treated for generalized 
intractable psoriasis or that home treatment is justified. The records do show that the physician states the item 
was requested by the enrollee. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy billed 
for date of service June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and binocular microscopy 
provided on September 21, 2023. 
 
You asked the Plan to waive the cost share for an office visit and binocular microscopy. You say that you 
disagree with the 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 $675 deductible which applies to hearing services and 
physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the hearing services and 
physician/practitioner services benefit category. You are being asked to pay $311.13 towards your deductible. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $675 deductible which 
applies to hearing services and physician/practitioner services. This cost sharing is a contractual obligation that 
had not been met at the time an office visit and binocular microscopy was received on September 21, 2023. Therefore, we decided that the Plan does not have to waive the cost share for an office visit and binocular 
microscopy provided on September 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back orthosis billed for date of service June 7, 2023. You asked the Plan to pay for the billed orthosis. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show that the enrollee was being treated for a spine injury or condition that 
would warrant an orthosis. The records do not show that an orthosis was part of the enrollees treatment plan 
for a specific condition. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the back orthosis billed for date of 
service June 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on May 19, 2023.

You asked the Plan to pay for the ambulance services. You say that the enrollee's secondary insurance did not pay this claim in full. The Plan denied your request. The Plan says you have already been paid for this transport by the enrollee's auto insurance.

The Plan must follow Medicare rules. Medicare rules say that ambulance suppliers must accept the Medicare allowed charge as payment in full.

In this case, records show that the enrollee's auto insurance has already paid your organization $1612.00 for this ambulance transport.  According to the Medicare ambulance fee schedule, the Medicare-allowed rate for the ambulance services you provided was $720.59 ($423.06 for code A0429, and $297.53, which is a total of 4 miles for code A0425). You have already been paid over the Medicare-allowed amount for the transport provided.  As a result, the Plan cannot be obligated to pay you additional monies, as you have already been paid more than the Medicare-allowed amount for the transport.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for two units of procedure code 95861 rendered on June 1, 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 that there was no specific rationale given for why additional units needed to be 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 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas." 
 
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 records both support that the 
additional unit was rendered and was medically reasonable and necessary in this case. The lower needle EMG 
(electromyography) had recording sites of abductor hallucis, gastroc S1, iliopsoas L1-3, peroneus longs L5 and 
S1, tibialis anterior L5, vastus medialis L2-4, and rectus femoris. The bilateral baseline lower needle 
electromyography activity was assessed and found to be free of spontaneous activity. Free running 
electromyography was monitored throughout the procedure with no reportable intraoperative events. The 
enrollee was paralyzed for entire procedure according to surgeons preference. Iliopsoas added due to previous 
fusion at L2-S1. Multimodality intraoperative neurophysiological monitoring was continuously carried out in 
an effort to safeguard neuroanatomical structures and neurophysiological function utilizing the modalities listed 
below. Somatosensory evoked potentials (SSEPs) were used to continuously monitor dorsal column functions 
during the entire procedure. Needle electromyography (EMG) was used to monitor individual nerve root status. 
Neuromuscular testing was employed to help validate the sensitivity of the needle-EMG testing during monitoring. 
 
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 
two units of procedure code 95861 rendered on June 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 22, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are asking for the review of the submitted 
documents. 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 March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 09, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on August 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower grab bar. 
 
You asked the Plan to pre-approve a shower grab bar. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a shower grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and photochemotherapy to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and photochemotherapy. You say that the services should be 
covered. The Plan denied your request. The Plan says this was not authorized. 
 
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 and photochemotherapy 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 waive the copayment for inpatient hospital care provided on January 
13, 2023, to January 20, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital 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 $200 
copayment for inpatient hospital care. 
 
You have been asked to pay a $200 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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 owe is $1,000 ($200 x 5 days = $1,000). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on January 13, 2023, to 
January 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency inpatient hospital services provided on July 
20, 2023, to July 23, 2023. 
 You asked the Plan to pay for the inpatient hospital services. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the member is responsible for paying for 
emergency services received outside of the United States at the time they receive services. The member is 
required to submit receipts to the Plan for reimbursement for the difference between the amount of the bill and 
their cost share for the services outlined in the Plan Evidence of Coverage (EOC). 
 
The Plan must follow Medicare rules. Medicare rules say that if you receive emergency services outside of the 
United States, you must pay the full cost of the emergency services at the time you receive services. Save your 
receipts and send copies with a reimbursement request to the Plan, and you will be reimbursed the difference 
between the cost of your bill and your cost share for the services provided.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency inpatient hospital services provided on July 20, 2023, to July 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have pay for non-emergency transportation services to your appointments 
from an out of network (OON) provider. 
 
You asked the Plan to pay for non-emergency transport taxi. You say that you need a different car service 
provider. The Plan denied your request. The Plan says out of network transportation is not a covered benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation from their preferred provider SafeRide. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have pay for transportation services to your appointments from an out of network (OON) 
provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73562 provided on August 28, 2023. 
 
You asked the Plan to pay for procedure code 73562. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that codes with a status indicator of Q1 are not 
separately payable.  
We looked at the file and Medicare rules. In this case, the service in dispute was billed along with code 99283. 
Code 99283 has a status indicator of V. Billed code 73562 has a status indicator of Q1. This means that this 
code is not separately payable. Therefore, we decided that the Plan does not have to pay for procedure code 
73562 provided on August 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that the patient had three different sites biopsied, and 
these services were medically necessary. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 22, 2022.