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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on February 23, 
2022, to February 26, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is being 
charged is correct. 
 
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 $275 copayment per day for days 1-5 and $0 after day 5. This applies to all admissions, including a 
transfer from another facility such as an acute rehabilitation or skilled nursing. 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. There were 3 days. $275 x 3 = $825. Therefore, results in the total cost 
sharing amount of $825. The enrollee has been asked to pay a $275 copayment per day for inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient hospital care 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 
copayment for inpatient hospital stay on February 23, 2022, to February 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0425, 
A0428). 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the enrollee needs 
transportation. The Plan denied your request. The Plan says the clinical indicates transportation other than an 
ambulance (e.g., private car, wheelchair van, etc.) could be utilized without endangering the individual's health, 
whether or not such other transportation is actually available. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation. Our reviewer says that non-emergency ambulance transportation is not medically reasonable 
and necessary. Our physician reviewer found that the enrollee is not bed-ridden and is able to walk with a 
walker. The destination is a physician's office, not a hospital or emergency room. The request does not meet the 
criteria and is not 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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0425, A0428).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on February 25, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the patient presented to to office with knee pain. 
This provider saw the the member in 2013 for chronic knee pain as well.  You said that this visit was medically 
necessary and should be covered. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. 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 the office visit and related services provided on February 25, 
2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on January 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an outpatient visit. You say that these services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 an outpatient visit provided on January 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), injection (20610), shoulder x-ray 
(73030), and triamcinolone acetonide (J3301) provided on May 16, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained before the services were rendered to 
the enrollee. 
 
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 in this case is not a network provider with the Plan. 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 the office visit (99204), injection (20610), shoulder x-ray 
(73030), and triamcinolone acetonide (J3301) provided on May 16, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2022 billed with 
codes 81235, 81276, 81210, 81275. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says this was not reported appropriately. 
 
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 
January 20, 2022 billed with codes 81235, 81276, 81210, 81275.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON office visit. You say that this visit was medically necessary. The Plan 
denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. 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 the office visit provided on April 6, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on May 16, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  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 an office visit (99213) provided on May 16, 2022 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for date of service August 2, 2021. 
 
You asked the Plan to pay for code 99291. You say that you have provided documentation to support the billed 
charges. The Plan denied your request. The Plan says the medical records do not support payment for this 
service. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically code 99291 is a time-based 
code, meaning that the total minutes spent providing critical care services must be documented in the medical 
record.  In this case, there is no documentation in the medical record of the number of minutes spent on this 
service. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for code 99291 billed for date of service August 
2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for home management training provided on 
April 7, 2022. 
 
You asked the Plan to waive the copayment for home management training. You say that you did not know you 
were enrolled in this plan. The Plan denied your request. The Plan says the claim has been reprocessed at the 
in-network benefit level. 
 
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 in-network therapy services.  
 
You have been asked to pay a $40 copayment for home management training. Home management training falls 
within the Outpatient Rehabilitation 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 copayment 
for home management training provided on April 7, 2022.  
 
Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the Kansas City CMS Regional Office so that it can look into your enrollment question.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive hereditary pharmacogenomic testing (81226, 
81225, 81227) provided on February 1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive hereditary pharmacogenomic testing. You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
services denied correctly as they were non-emergent and prior authorization was not obtained. 
 
  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 comprehensive hereditary pharmacogenomic 
testing (81226, 81225, 81227) provided on February 1, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on March 
19, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they were non-emergent and prior authorization was not obtained. 
 
  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 subsequent nursing facility care (99309) provided 
on March 19, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing (80307, G0483) provided on 
February 22, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 laboratory drug testing (80307, G0483) provided 
on February 22, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for 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, for 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 June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 the laboratory 
services provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on June 8, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  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 an office visit (99214) provided on June 8, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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, for 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 March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (code 80050) billed for date of 
service July 28, 2020. 
 
You asked the Plan to pay for code 80050. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code is not covered.  All other codes billed for this 
date of service have been paid. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. Therefore, we decided that the Plan does not have to pay for the general health panel (code 
80050) billed for date of service July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided by an out-of-
network provider on March 2, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that medical necessity is pre-
established with the patient and facility. You say that the medical records prove the need for the services 
rendered and the provider should be paid. The Plan denied your request. The Plan says this provider is not a 
network provider and services were not approved in advance. 
 
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 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 the domiciliary or rest home visit provided by an 
out-of-network provider on March 2, 2022.