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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 29, 2022, to 
November 7, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of E43 (unspecified severe 
protein calorie malnutrition) and I50.21 (acute systolic congestive heart failure). 
 
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 codes E43 defined as unspecified severe 
protein calorie malnutrition and I50.21 defined as acute systolic congestive heart failure. 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 physician reviewer found that the medical records did not support diagnosis codes E43 and I50.21. The 
patient had volume overload that resolved with simple diuresis and the echocardiogram did not show a 
decreased ejection fraction.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 29, 2022, to November 7, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care provided on July 31, 2023. 
 
You asked the Plan to pay for the initial hospital care. 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 initial hospital care 
provided on July 31, 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 July 26, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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 July 26, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left eye tributary 
(branch) retinal vein occlusion with macular edema. He has not tried and failed the Plan's required drug, 
bevacizumab. The records do not show that the required drug would be contraindicated or less effective; 
therefore, Vabysmo is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vabysmo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87481, 87150) provided on May 15, 
2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87798, 87481, 87150) provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 18, 2023, billed with 
code 81000. 
 
You asked the Plan to pay for procedure code 81000. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says you have an inappropriate CLIA certificate to perform 
the test at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that CLIA lists requirements for laboratories 
performing only certain tests to be eligible for a certificate of waiver or a certificate for PPMP.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 81000 have not been met. Specifically, the test denoted by code 81000 is listed in 
the rules as a physician-performed microscopy procedure. You have documented that your CLIA certificate is a 
Certificate of Waiver. The certificate clearly states that a laboratory operating under a Certificate of Waiver is 
permitted to perform only waived tests, not including physician-performed microscopy procedures. Therefore, 
we decided that the Plan does not have to pay for laboratory testing provided on July 18, 2023, billed with code 
81000.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump, any type (E0218) 
provided April 24, 2023, to May 17, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says this service is 
not a covered benefit under Medicare or the Plan. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump, any type (E0218) provided April 24, 2023, to 
May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on June 8, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that the enrollee has unlimited acupuncture 
visits. The Plan denied your request. The Plan says the enrollee's annual acupuncture benefit has been 
exhausted. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record shows the enrollee had received 20 
acupuncture sessions in 2023. Therefore, we decided that the Plan does not have to pay for the acupuncture 
services provided on June 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96372, 90471, and 90714 provided on 
August 31, 2023. 
 
You asked the Plan to pay for procedure codes 96372, 90471, and 97014. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 96372 and 90471 are a packaged service due to being billed on the same claim as code 
99284, which has a status indicator of V. Additionally, Medicare says that unconditionally packaged services 
are identified in the OPPS Addendum B with status indicator of N and these services are not paid separately 
since payment is included in the APC. Code 90714 is identified with a status indicator of N. Therefore, we 
decided that the Plan does not have to pay for procedure codes 96372, 90471, and 90714 provided on August 
31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 15, 2022, to 
April 13, 2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA is on file and you 
believe you are in-network. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 15, 2022. The NOA was not received by the Plan until September 
22, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 15, 2022, to April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on August 
31, 2023. 
 
You asked the Plan to pay for the chronic care management services. 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 chronic care 
management services provided on August 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided on October 24, 2022. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter are met. 
 
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 definitive UDT for 15-21 drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that screening was 
positive for opioids, cannabinoids, without clonazepam, the last two being unexpected. Definitive testing was 
warranted, but only for 2 drug classes, not the 15-21 tested on this date. Therefore, the LCD criteria is not met.  
 
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 definitive UDT for 15-21 drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on October 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided on 
August 06, 2023. 
 
You asked the Plan to waive the copayment for an emergency department visit. You say that you were not seen 
by the 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an emergency department 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 
department visit provided on August 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiographic procedure (76499) provided on May 11, 2023. 
 
You asked the Plan to pay for a radiographic procedure. You say that this is supported by the records. The Plan 
denied your request. The Plan says this was not billed with a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Medicare includes the TC of radiology 
services for hospital inpatients, except Critical Access Hospitals (CAHs), in the prospective payment system 
(PPS) payment to hospitals. We looked at the file and Medicare rules. 

The record shows that the radiology service at issue was provided to 
a hospital inpatient, but it was not billed with a modifier to indicate only the professional component, not the 
technical component, is being billed. Based on this information, we decided that Medicare rules for coverage of 
a radiographic procedure have not been met. Therefore, we decided that the Plan does not have to pay for a 
radiographic procedure (76499) provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on September 07, 
2022. 
 
You asked the Plan to pay for the ophthalmological services. 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 ophthalmological 
services provided on September 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an abatacept injection, and the saline 
solution infusion provided on August 31, 2023, to September 14, 2023. 
 
You asked the Plan to waive the coinsurance for an abatacept injection, and the saline solution infusion. You 
say that you were told that you would have a $95 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an abatacept injection, and the saline solution infusion. 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 amount you owe is $673.24 ($3,366.23 
allowed amount x 20% = $673.24). Therefore, we decided that the Plan does not have to waive the coinsurance 
for an abatacept injection, and the saline solution infusion provided on August 31, 2023, to September 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incomplete endodontic therapy (D3332). 
 
You asked the Plan to pre-approve D3332. You say that you need this dental work. The Plan denied your 
request. The Plan says the denied dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
incomplete endodontic therapy (D3332).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 16, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you are an independant laboratory and depend 
on the clinic and provider to verify plan coverage. 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 August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 rendered on December 13, 2021. 
 
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 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 code 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 medical records do not 
support that a separate evaluation and management service was performed outside of the wound debridement. 
The enrollee was seen only for the debridement. 
 
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 procedure code 99213-25 rendered on December 13, 2021.