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

 
We decided that the Plan does not have to pay for the laboratory service provided on April 10, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on April 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued daily 
inpatient care.  The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more stable and ready for a lower level 
of 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for G0277 (4 units) provided on March 28, 2023. 
 
You asked the Plan to pay for G0277. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the records do not support the number of units 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 G0277 is hyperbaric oxygen under pressure, full body 
chamber, per 30 minute interval. 
 
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 G0277. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the claim reported 4 units of service provided; however, the medical 
record documents 90 minutes of oxygen with 2 5-minute air breaks. Therefore, 4 units are not supported as the code description is per 30 minute interval. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0277 have not been met. Therefore, we decided that the Plan does not have to 
pay for G0277 (4 units) provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 27, 2022. 
 
You asked the Plan to pay for the medical services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says you billed this claim with an incorrect Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on November 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that the CGM is a medical necessity. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME 
products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, 
the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use 
of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G7 sensor. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 
sensor.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 06, 2023. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on April 06, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency 
transport, and ground mileage. 
 
You asked the Plan to pre-approve the ambulance service and ground mileage. You say that the transport is 
medically necessary. The Plan denied your request. The Plan says you do not have any medical needs which 
need to be monitored closely during transportation by a medical professional. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground 
mileage. Our reviewer says that the ambulance services are not medically necessary. Our physician reviewer 
found the documentation does not support that another means of transport (such as stretcher van, wheelchair 
van, taxi, private car, or other type of vehicle) is/was contraindicated for you in this case. The documentation 
does not support that you need the expertise, services and lifesaving and life-sustaining equipment that only a 
fully equipped ambulance can provide for a safe transport. The documentation also does not support that the 
ambulance transport is reasonable and 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 the ambulance service and ground mileage. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency 
transport, and ground mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided by an acupuncturist on 
January 17, 2023, to February 14, 2023.  
 
You asked the Plan to pay for acupuncture services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says Acupuncturists are included in the list of individuals that are not 
eligible to enroll in Medicare. Therefore, Acupuncturists are not able to be reimbursed by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for acupuncture services provided by an 
acupuncturist on January 17, 2023, to February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total disc arthroplasty of L4-L5. 
 
You asked the Plan to pre-approve the total disc arthroplasty of L4-L5. You say that your surgeon says you 
need this surgery and will need additional surgery in five years if the total disc arthroplasty is not performed. 
You say the bone density report is showing a negative osteopenic range. The Plan denied your request. The 
Plan says  the total disc arthroplasty is not medically necessary for enrollees over 60 years of age. 
 
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 the total disc arthroplasty of L4-L5. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are being treated for spondylolisthesis at L5-S1, degenerative disc disease with 
partial collapse at L4-L5, severe degenerative disc disease with significant collapse at L5-S1, and instability 
with unstable flexion/extension. The criteria for coverage do not support the requested LADR for beneficiaries 
over 60. Therefore, you do not meet the indications for coverage. 
 
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 total disc arthroplasty of L4-L5 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the total disc arthroplasty of L4-L5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foot orthotics (L1940 x2, L2330 x2, 
L2820 x2, L2840 x2, L1940 x2) provided on March 10, 2023. 
 
You asked the Plan to waive the coinsurance for foot orthotics (L1940 x2, L2330 x2, L2820 x2, L2840 x2, 
L1940 x2). You say that you were not told of any service charges prior to your appointment. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for foot orthotics (L1940 x2, L2330 x2, L2820 x2, L2840 x2, 
L1940 x2). This item/service falls within the prosthetic devices and related 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. The total you owe is 
$457.92 ($2,289.66 allowed amount x 20% = $457.92). Therefore, we decided that the Plan does not have to 
waive the coinsurance for foot orthotics (L1940 x2, L2330 x2, L2820 x2, L2840 x2, L1940 x2) provided on 
March 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips for 
your doctors visits. The Plan denied your request. The Plan says you have exceeded the maximum 
transportation benefit allowed per the plan. 
 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 a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance, lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve injections. You say that you are requesting reconsideration and have 
attached medical records for review. The Plan denied your request. The Plan says notes submitted did not 
provide documentation of the percentage of pain relief the enrollee had received after having previous 
injections and over what period of time he had the pain relief. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of non-invasive conservative care since onset of left-
sided symptoms/radiculopathy. The review has determined that the enrollee does not meet the coverage 
indications for the requested procedure. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance, 
lumbar or sacral, single level (64483).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network eye injection provided on 
March 31, 2022, and June 30, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network eye injection. You say that this plan is not 
paying enough towards these visits, and you cannot afford all of these bills. If this does not change you will be 
changing plans. 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% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 The allowed amount on March 31, 2022, for this procedure was $70.41 ($70.41 x 20% = $14.08). 
The allowed amount on June 30, 2022, was $67.86 ($67.86 x 20% = $13.57). 
Your combined amount is $27.65 ($14.08 + $13.57 = $27.65) for these services. 
 
You have been asked to pay $27.65 a combined coinsurance for an in-network 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. Therefore, we decided that the Plan does not have to waive the 
coinsurance for an in-network eye injection provided on March 31, 2022, and June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen. 
 
You asked the Plan to pre-approve Privigen. You say that the requested procedure is required to treat the 
enrollee's condition. 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 Privigen.  
 
Benefits for Privigen 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 pay for medical services provided from January 16, 2023, to January 
17, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have sent in medical records to support 
payment. The Plan denied your request. The Plan says you billed these services with an incorrect Place of 
Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided from January 16, 2023, to January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are a small facility and do not work with 
the plans in this way. 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 laboratory services 
provided on December 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 13, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
the diagnoses billed. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that F32.A has an Excludes1 note in relation to F31.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on April 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 19, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you are unable to 
afford the copayment applied. 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 $95 
copayment for Emergency Care. 
 
You have been asked to pay a $95 copayment for an emergency room (ER) visit. This item/service falls within 
the Emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on April 19, 2023.