Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on May 
02, 2023, to May 08, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $275 
copayment for inpatient hospital care. 
 
You have been asked to pay a $275 copayment for the inpatient hospital stay. 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. You have been asked to pay a total of $1,650 for the inpatient hospital stay ($275 
copayment x 6 days = $1,650). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on May 02, 
2023, to May 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 14, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were told that the doctor was a 
primary care provider. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on August 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve the intraosseous ablation of the basivertebral nerve. You say that this 
procedure addresses vertebrogenic pain by addressing a gap in the treatment algorithm for patients suffering 
from chronic low back pain. You say the enrollee has tried and failed conservation treatment without relief.  
The Plan denied your request. The Plan says  the intraosseous ablation of the basivertebral nerve is not 
medically necessary. The Plan says there is not enough research to show that the service improves net health 
outcomes in patients with vertebrogenic back pain.  
 
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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental therapy, and it is the 
subject of ongoing clinical trials. Therefore, the request is deemed not medically 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 intraosseous ablation of the basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral 
nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, nonsegmental home model 
device (E0650). 
 
You asked the Plan to pre-approve a pneumatic compressor device. You say that you had a total knee 
replacement, and your doctor ordered the requested device to help with reducing swelling in your left knee. The 
Plan denied your request. The Plan says the request is not medically necessary because the records show you 
do not have lymphedema. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compressor device. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you underwent a left 
total knee arthroplasty on October 4, 2023. You presented to physical therapy with pain, and you are getting 
more confident with your walker. The left knee pain is anterior and medial and rated at 4/10. Edema is present 
but within normal limits. The range of motion is decreased. You continue with therapy. However, you are not 
documented to have venous stasis ulcer(s) or significant edema. The physical therapy note cited the edema that 
is present is within normal limits. Therefore, you do not meet the criteria for the pneumatic compression 
device. 
 
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 pneumatic compressor device have not been met.  Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compressor, nonsegmental home model device (E0650).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services (procedure code 99285) rendered on June 3, 
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 Current Procedural Terminology (CPT) code 99285 (1 Unit) remains not supported. 
 
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making." 
 
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 history and physical were 
appropriately documented. The documentation medical decision making of high complexity. 
 
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 
emergency room services (procedure code 99285) rendered on June 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 20, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of 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 laboratory service 
provided on June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on June 14, 2023. 
 
You asked the Plan to pay for the diagnostic radiology services. You say that the chiropractor could not start 
treatment until he assessed your medical issues. The Plan denied your request. The Plan says the Plan covers 
only manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for diagnostic radiology services provided on June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eight units of procedure code 88360 rendered on December 
14, 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 there was no specific rationale given for why the 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 88360 is "Morphometric analysis, tumor 
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or 
semiquantitative, per specimen, each single antibody stain procedure; manual." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee had morphometric 
analysis performed on tissue biopsy samples. The documentation does support that additional units were 
provided but there is no specific documentation why this additional testing was medically necessary. 
 
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 eight units of procedure code 88360 rendered on December 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network Denosumab injection 
provided on August 24, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network Denosumab injection. You say that you have 
had this done ever 6 months and have never 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an in-network Denosumab 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. The total you owe is $276.13 ($1380.65 x 20% = $276.13). Therefore, we 
decided that the Plan does not have to waive the coinsurance for an in-network Denosumab injection provided 
on August 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) performed 
on March 22, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for the requested CPT 99285. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 records do not support an 
appropriate level of history and physical. The records do not show high complexity medical decision making. 
 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 emergency room services (procedure code 99285) performed on March 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (99224) provided on December 
27, 2022. 
 
You asked the Plan to pay for the evaluation. You say that CPT code 99224 was billed correctly and should be 
paid. The Plan denied your request. The Plan says there are designated evaluation and management (E/M) CPT 
codes to use for specific places of treatment. Additionally, per AMA CPT Manual "The following codes are 
used to report evaluation and management services provided to patients designated/admitted as "observation status" in a hospital. The Plan says that another evaluation CPT code is more appropriate for the service 
provided. 
 
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 99224 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused 
interval history; Problem focused examination; Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is stable, recovering, or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We asked our physician 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 evaluation. Our reviewer found the medical records 
do not support code 99224. The documentation does not support medical decision making of high complexity, 
neither the exam or interval history are detailed. 
 
We looked at this coder's review, the file, and Medicare rules. We find that code 99224 is for outpatient care 
and was incorrectly billed with an inpatient POS code. Based on this information, we decided that Medicare 
rules for coverage of the evaluation have not been met. Therefore, we decided that the Plan does not have to 
pay for subsequent observation care (99224) provided on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99222) 
rendered on July 11, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records submitted do not include an evaluation and management note for the billed 
provider. 
 
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 99222 is "Initial 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 moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 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 does not 
support an appropriate history, exam, or moderate complexity of decision making or at least 55 minutes 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 evaluation and management services (procedure code 99222) rendered on July 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 7 units of procedure code 87481 performed on June 27, 
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 there was no specific rationale given for why the 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 87481 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Candida species, amplified probe technique." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee had nucleic acid 
testing for infection. The records do support that additional units were provided but there is no specific 
documentation as to why the testing was medically necessary. 
 
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 7 units of procedure code 87481 performed on June 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have pay for inpatient hospital care provided on November 22, 2022, to 
November 24, 2022. 
 
You asked the Plan pay for inpatient hospital care. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says an authorization issued by the Veterans' Administration 
(VA) binds the VA to pay in full for the items and services provided. No payment is made under Medicare for 
such authorized services. 
 
The Plan must follow Medicare rules. The rules say that VA facilities and military hospitals are excluded from 
participating in Medicare. The rules also 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 pay for inpatient hospital care provided on 
November 22, 2022, to November 24, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from January 16, 2023, to January 
18, 2023 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were supported by the medical records. Our physician 
reviewer found that the enrollee had systemic inflammatory response syndrome with a gastrointestinal source, 
so code A41.9 is justified. The documentation more supports DRG 872 rather than DRG 392. 
 
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 rendered from January 16, 2023, to January 18, 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.