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

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from February 25, 2022, to March 18, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel you did not receive the 
proper care at this facility. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 per 
day for days 1-20, $80 per day for days 21-44, and $0 per day for days 45-100 for each benefit period.  
 
The file shows that you were in the nursing facility from February 25, 2022, to March 18, 2022 (22 days). You 
have only been asked to pay $20 per day for the first 20 days of SNF care, for a total of $400. The SNF care 
falls within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) care provided from February 25, 2022, to March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract in place 
which indicates that laboratory testing is bundled into payment for dialysis care. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Tumor Origin panel provided on December 7, 
2021, billed with code 81479. 
 
You asked the Plan to pay for the Tumor Origin panel. You say that this was a medically necessary test that 
was ordered by the physician. The Plan denied your request. The Plan says this single unit of code 81479 was 
billed on a claim separate from multiple other codes. Since this is for a single panel, only one code is payable. 
 
Please note: The Plan did not support that any other codes were billed for this date of service. As such, we 
disregarded the Plans rationale.  
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic lab testing must be ordered by a 
treating physician.  
 
We looked at the file and Medicare rules. The documentation submitted does not support that the Tumor Origin 
panel was requested. The order form is for the xF panel, a liquid biopsy of 105 genes. As there is not an order for the testing rendered, Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay 
for the Tempus Tumor Origin panel provided on December 7, 2021, billed with code 81479.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an X-ray exam of shoulder (73030) provided on May 12, 2021. 
 
You asked the Plan to pay for a shoulder X-ray. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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, the case record supports that the service at issue as provided but 
does not document that it was ever billed. It is the Plan's responsibility to substantiate its denial with evidence. 
In this case, the denial has not been substantiated, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for an X-ray exam of shoulder (73030) provided on May 12, 2021.  
 
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 lab services provided on April 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on April 5, 
2022. 
 
You asked the Plan to pay for this medication. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this medication is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
(A9270) provided on April 5, 2022.  
 Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT provided on February 16, 2022, by an OON provider. 
 
You asked the Plan to pay for a CT. You say that you are requesting a reconsideration due to the incorrect 
information provided by the enrollee prior to the date of service. The Plan denied your request. The Plan says 
the out-of-network services were not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a CT provided on February 16, 2022, by an OON 
provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for lab services (80048, 87426, 85027, 85610) provided 
from February 23, 2022, to March 4, 2022. 
 
You asked the Plan to hold you harmless for lab services. You say that these services were referred by your 
provider and you only agreed to have them done because you were assured that they would be covered by your 
insurance. The Plan denied your request. The Plan says that these services were billed with an incorrect 
modifier and were performed by a provider who was not in-network at the time of services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You say that you were referred for lab services by a contract provider. The Plan has not made any attempt to 
clarify if the referring provider is part of their network. The file does not show that the Plan provided notice 
that lab services would not be covered. Under Medicare rules, this means lab services is considered approved 
by the Plan. In addition, the Plan denied these services on the basis that they were not billed according to 
Medicare regulations. As the enrollee, you are not responsible for billing issues between the provider and the 
Plan. Therefore, we decided that the Plan has to hold you harmless for lab services (80048, 87426, 85027, 
85610) provided from February 23, 2022, to March 4, 2022.  
 
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 services related to end-stage renal disease 
(ESRD) provided on December 9, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract which 
indicates that payment for lab testing is made to the facility. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
22, 2019, to June 26, 2019. 
 
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 a DRG assignment change was appropriate.  
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 DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that the enrollee was admitted and evaluated by Infectious Disease. Cultures 
were negative and the antibiotics were discontinued. There was no clinical or laboratory evidence of sepsis. 
The review has determined that the appropriate DRG is DRG 308: CARDIAC ARRHYTHMIA AND 
CONDUCTION DISORDERS WITH MCC.  
 
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 to the enrollee from June 22, 2019, to June 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided February 4, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that the enrollee did not require transport 
because it was determined that symptoms were not related to a heart attack and the weather was severe. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on February 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should be paying for 
more. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been applied correctly. Therefore, we decided that the 
Plan does not have to pay for a crown (D2740) provided by a participating provider on March 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99223) provided on November 25, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that you have provided medical records to support 
the services at issue. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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, the Plan has indicated that the service at issue is included in 
revenue code 0762. Current Procedural Terminology (CPT) code 99223 cannot be denied as bundled into a 
revenue code. Code 0762 is not a valid CPT code. 
 
It is the Plan's responsibility to substantiate its denial with evidence. In this case, the denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for initial hospital 
care (99223) provided on November 25, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided on 
January 7, 2022, and January 8, 2022. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that you feel the costs 
should be covered du to your COVID-19 diagnosis. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $270 
copayment for each one-way ambulance trip.  
 You have been asked to pay a $270 copayment for each ambulance transportation, for a total of $540. Please 
note that there are no COVID-19 cost share waivers that apply to transportation. The ambulance transportation 
falls within the Ambulance 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. Therefore, we decided that the Plan does not have to waive the copayments for 
ambulance transportation provided on January 7, 2022, and January 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 26, 2021, billed 
with codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was billed correctly and is medically 
necessary testing. The Plan denied your request. The Plan says this was not correctly billed with a single panel 
code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 26, 
2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided 
on April 7, 2022. 
 
You asked the Plan to pay for limited oral evaluation  problem focused. The Plan denied your request. The 
Plan says the benefit is only covered once per Plan year. 
 
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 pay for limited 
oral evaluation  problem focused (D0140) provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract that 
indicates that laboratory services are not separately payable to the laboratory. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Spinal Simplicity interspinous-interlaminar fusion 
device (Minuteman device) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that failure of conservative treatment including epidural 
steroid injections, medial branch block and 3-6 months of physical therapy was identified. The Plan denied 
your request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Spinal Simplicity interspinous-interlaminar 
fusion device (Minuteman device) for the enrollee.