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

 
We decided that the Plan has to pay for procedure codes 36558 and 76937 rendered on June 7, 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 that the records do not support the services 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 
the denied codes is: 
 
CPT 36558: 
 
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years 
or older 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
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 documentation supports that the 
services in question were rendered and appropriately coded. There is satisfactory documentation that a tunneled 
central line was placed via the internal jugular vein. There is satisfactory documentation that the line was 
placed centrally specifically to the superior vena cava. Additionally, there is documentation that ultrasound 
guidance for access was utilized. As the primary procedure as coded was rendered, there is no reason now to 
deny the add on code. 
 
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 
procedure codes 36558 and 76937 rendered on June 7, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided January 11, 2023 to 
January 13, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the enrollee's needs could have been met in the outpatient 
observation setting. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the records do not suggest that at the time of admission that the expectation that the 
patient's hospital stay would span two midnights. The patient's condition improved rapidly. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided January 11, 2023 to January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 2, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from December 5, 2022, to 
December 16, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis code A41.9 should be the principal diagnosis for this episode of care. The Plan denied your request. 
The Plan says that diagnosis code A41.9 is not supported, which resulted in a DRG change. 
 
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 with diagnosis code A41.9, defined as Sepsis, unspecified 
organism. 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 diagnosis code A41.9 is supported. Our physician reviewer 
found the enrollee had systemic inflammatory response syndrome (SIRS) criteria with a diagnosis of 
pneumonia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided from December 5, 2022, to December 16, 2022, at the DRG originally billed.  
  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 waive the coinsurance for the chiropractic services provided on 
January 16, 2023. 
 
You asked the Plan to waive the coinsurance for the chiropractic services. You say that you were told you 
would be reimbursed a larger amount. 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 50% 
coinsurance for out-of-network chiropractic services.  
You have been asked to pay 50% coinsurance for the chiropractic services. This item/service falls within the 
out-of-network 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 you owe is $19.08 ($38.17 allowed amount x 50% coinsurance = 
$19.08). Therefore, we decided that the Plan does not have to waive the coinsurance for the chiropractic 
services provided on January 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on May 14, 2022. 
 
You asked the Plan to pay for the x-ray. You say that you are requesting reconsideration for the denied claim. 
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 x-ray provided on 
May 14, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost for the Levetiracetam injection. We decided that the Plan does 
not have to waive the cost for the echocardiography, and myocardial perfusion imaging.  You asked the Plan to waive the cost for an in-network echocardiography, myocardial perfusion imaging, and 
the Levetiracetam injection provided on January 18, 2023. You say that no one discussed these large 
copayments with you before preforming the test. You feel blindsided by this, as you are on a fixed income. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost for the Levetiracetam injection.  
 
The Plan follows Medicare rules. 
The file shows that you have a medical indication for which Medicare will cover the above services. Therefore, 
we decided that the Plan has to waive the cost for the Levetiracetam injection.  
 
We also decided that the Plan does NOT have to waive the cost for the echocardiography, and 
myocardial perfusion imaging. 
 
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 the echocardiography, and a $250 copayment myocardial perfusion imaging ($200 + $250 = 
$450 total). Therefore, we decided that the Plan does not have to waive the cost for the echocardiography, and 
myocardial perfusion imaging. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy treatment to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve chemotherapy treatment. You say that you have been seeing the requested 
provider and wish to continue. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
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 
chemotherapy treatment 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 subsequent hospital care (procedure code 99233) rendered on 
March 14, 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 Current Procedural Terminology (CPT) 99233 rendered on March 14, 2023. 
 
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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level, or that 50 minutes 
or more were spent. 
 
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 subsequent hospital care (procedure code 99233) rendered on March 14, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services after 
September 8, 2023. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would benefit from this care.  The Plan 
denied your request. The Plan says it is not reasonable or necessary to continue SNF care.  
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal.  
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before September 9, 2023. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan does not have to pay for continued skilled nursing facility (SNF) services after September 8, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99220. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 99497.  
 
You asked the Plan to pay for the medical services provided on October 27, 2022, billed with codes 99220 and 
99497.. You say that the services were medically necessary and should be paid.  The Plan says that code 99220 
is not supported since there is no documentation to support that the enrollee was under observation status. 
99497 is denied as the required modifier is missing.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 99220.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we find that insufficient evidence was presented to support the 
Plan's rationale that the enrollee was not admitted to observation status. The record clearly indicates that the 
treating physician felt that the enrollee would require further testing and would be discharged no sooner than 24 
hours later. In addition, the Plan failed to provide evidence from the facility claim to show that there was no 
observation care, which would be available to them.  Therefore, we decided that the Plan has to pay for the 
services described by procedure code(s) 99220.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99497. 
 
The Plan follows Medicare rules. The Plan must follow Medicare rules. Medicare rules say that providers must 
report services correctly. Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 99497 is a Column 2 code in relation to Column 1 code 99220. This 
claim has not been billed an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code(s) 99497. 
 
 
 
 
 
 
 
 
 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: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost for a $59.04 copay for the cardiovascular stress test, and a 
$49.59 coinsurance for the Levetiracetam Injection. We decided that the Plan does not have to waive the 
cost for a $175 copay for the nuclear stress test.  
 You asked the Plan to waive the cost for an in-network nuclear stress test provided on May 10, 2023. You say 
that you were severely ill due to this test and feel you should not have to pay anything for it. The Plan says that 
this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost for a $59.04 copay for the cardiovascular stress test, and a 
$49.59 coinsurance for the Levetiracetam Injection  
 
The Plan follows Medicare rules.  
The file shows that you have a medical indication for which Medicare will cover outpatient diagnostic tests and 
therapeutic services and supplies.  
 
Therefore, we decided that the Plan has to waive the cost for a $59.04 copay for the cardiovascular stress test, 
and a $49.59 coinsurance for the Levetiracetam Injection.  
 
We also decided that the Plan does NOT have to waive the cost for a $175 copay for the nuclear stress 
test. 
 
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 a $175 copay for the nuclear stress test. Therefore, we decided that the Plan does not have to 
waive the cost for a $175 copay for the nuclear stress test. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed (E0303). You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for a heavy duty extra wide hospital bed (E0303). 
 The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0303) is 
covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight 
is more than 350 pounds but does not exceed 600 pounds. In this case, the file shows that the enrollee's weight 
is less than 350 pounds. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra 
wide hospital bed (E0303).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc or Supartz FX is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We looked at the file and Medicare rules. No medical records were provided for review. Without clinical 
documentation, it cannot be determined if step therapy rules were met. Based on this information, we decided 
that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
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 
February 02, 2020. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you do not 
understand why you are receiving a bill after 3 years. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 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 February 02, 2020.