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

 
We decided that the Plan does not have to pay for the home visit and debridement provided on February 27, 
2023. 
 
You asked the Plan to pay for the home visit and debridement. You say that the service was 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 the home visit and 
debridement provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99213 and J7328 for date of service 
December 14, 2022.  
You asked the Plan to pay for procedure codes 99213 and J7328. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. Code J7328 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. Code 99213 at issue is within the global surgery period of code 
20610 provided on December 14, 2022. Modifier -25 was used for code 99213. We find that the required 
modifier to indicate this was not used. As such, the billing rules for these services have not been met. 
 
We find that code J7328 is not supported in the medical record. Specifically, the medical claim form submitted 
does not include a National Drug Code (NDC) number, quantity, or measure of units for the billed drug. This 
means the service, modifier, and units cannot be verified. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99213 and J7328 for date of 
service December 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 16, 2023, to 
May 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from April 16, 2023, to May 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital stay and hospital 
observation on February 11, 2023, to April 20, 2023. 
 
You asked the Plan to waive the copayments for inpatient hospital stay and hospital observation. You say that 
you want to appeal the amount being charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $395 copayment per admission for each medically necessary inpatient stay. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. The enrollee must pay a $250 copayment for outpatient hospital 
observation services. Observation services are hospital outpatient services given to determine if you need to be 
admitted as an inpatient or can be discharged. There were four visits for the copayment of $395. 4 x $395 = 
$1,580. There was one visit for a copayment of $250. For all services it's, $1,580 + $250 = $1,830. Therefore, 
results in the total cost sharing amount of $1,830. 
 
The enrollee has been asked to pay a $395 copayment each for inpatient hospital stay and a $250 copayment 
for hospital observation. This item/service falls within the inpatient hospital care and outpatient hospital 
observation benefit category. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for inpatient 
hospital stay and hospital observation on February 11, 2023, to April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to go to a rehabilitation hospital. The Plan 
denied your request. The Plan says you do not meet all the requirements. The Plan says that the services needed 
may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 15, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration asking for payment. 
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 lab testing provided on 
May 15, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Gammagard. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that Gammagard is 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Gammagard is medically necessary. Our physician reviewer found that the requested use of Gammagard is not 
FDA-approved. However, Gammagard is supported by one of the major drug compendia and by clinical 
research. Gammagard is also safe and effective and otherwise reasonable and necessary for the enrollee. 
Additionally, the enrollee meets the LCD coverage criteria. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Gammagard.  
 
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 continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is not on medications that cause low blood sugars, and 
we are not told of low blood sugars. Although the CGM may help the enrollee, the coverage criteria not met. If 
insulin is added, the case should be re-reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal polymerase chain reaction (PCR) testing (87481, 
87798) provided on November 18, 2022. 
 
You asked the Plan to pay for the fungal PCR testing. You say that this procedure was performed to hasten 
definitive diagnosis and to efficiently treat the enrollee's condition. The Plan denied your request. The Plan 
says this testing is experimental or investigational. 
 
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 pay for the fungal PCR testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the longstanding standard of care for the evaluation of fungus in toenails is the 
performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this patients toenail required PCR testing as compared to KOH 
and fungal culture. Therefore, it is my opinion that the PCR testing of this enrollees toenail on November 18, 
2022, was not medically reasonable or necessary at this time. 
 
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 fungal PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the fungal polymerase chain reaction (PCR) testing (87481, 87798) provided on 
November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on March 22, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and request reconsideration. The Plan denied your request. The Plan says PCDs are covered in a 
home setting, not a ambulatory surgical center. 
 
The Plan follows Medicare rules. The rules say that pneumatic devices are covered for the treatment of 
lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the PCDs are not covered by Medicare when the place of 
service is an ambulatory surgical center. The records show that you billed with a place of service 24, which is 
an ambulatory center. The NCD states that PCDs are covered in the home setting and Medicare does not 
consider an ambulatory surgical center a home. Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device (E0675) and a segmental gradient pressure pneumatic appliance, half leg 
(E0673) provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum assisted suspension system (VASS) (L5781) and 
microprocessor foot (L5973). 
 
You asked the Plan to pre-approve a VASS and microprocessor foot. You say that the items are medically 
necessary. The Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 a VASS and microprocessor foot. Our 
reviewer says that the requested items are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a K3 ambulator and needs these items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a VASS and microprocessor foot have been met. Therefore, we decided that the 
Plan has to pre-approve a vacuum assisted suspension system (VASS) (L5781) and microprocessor foot 
(L5973).  
 
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 waive the copayment for an acute inpatient stay provided from 
November 12, 2022, to November 15, 2022. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you should not be 
respocible for this copayment, as you were transferred from one facility to this one. Her old facility should 
have paid the copayments. 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 $400 
copayment per day for days 1 - 4 for inpatient hospital service.  
 
You were in the hospital for 3 days, resulting in a $1,200 total copayment ($400 x 3 = $1,200). 
 You have been asked to pay a $1,200 total copayment for an acute inpatient stay. This item/service falls within 
the inpatient hospital service benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an acute 
inpatient stay provided from November 12, 2022, to November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on October 25, 2022, billed 
with procedure code 93229. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
code. 
 
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 93229 is external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG (electrocardiogram) data storage (retrievable with query) with ECG triggered and patient 
selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and 
emergent data reports as prescribed by a physician or other qualified health care professional. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the procedure report does not include 
sufficient documentation to confirm procedure code criteria have been met. Medical record documents holter 
monitor however, does not include documentation of cardiac recording type. Also, report does not support the 
technical component of procedure, as documentation of connection and patient instruction was not found in 
medical record. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on October 25, 2022, billed with procedure 
code 93229.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 6, 2022, to June 
4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 6, 2022, to June 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 10, 2022. 
 
You asked the Plan to pay for the medical services. You say that you have been seeing this patient for several 
years and have been trying to have the provider name on the patient's insurance card updated. The Plan denied 
your request. The Plan says you did not timely file this claim. The Plan follows Medicare rules. The rules say 
that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after 
the date of service. The record shows that a claim for the medical services was not filed until February 23, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for medical services provided on February 10, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76641, 76981, and 76982 billed for date of 
service March 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that it was medically necessary to do an ultrasound 
with elastography. The Plan denied your request. The Plan says payment for code 76981 and 76982 is bundled 
into payment for code 76641. 
 
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 76981 and 76982 are column II codes to column I code 76641. 
Codes 76981 and 76982 were billed with the XU modifier. The records do not show that these services were 
unusual components of the main service.  
 
The CPT Code Manual definition of code 76641 is ultrasound, breast, unilateral, real time with image 
documentation, including axilla when performed; complete. We find that CPT code 76641 is not supported. 
The records do not document that all four quadrants were examined. 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 
76641, 76981, and 76982 billed for date of service March 3, 2023.