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

 
We decided that the Plan does not have to pay for initial hospital care (99223) billed for date of service January 
30, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that you have provided medical records to support 
the service billed. The Plan denied your request. The Plan says rules for payment have not been met because 
the available medical records do not support the service 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 initial hospital care. Our reviewer says that the services at 
issue do not meet criteria for payment. Our reviewer found that the available medical record does not support 
level of service 99223. The procedure report documents history, vital signs, and plan of care. Billing of CPT 
code 99223 requires 3 key components: a comprehensive history, a comprehensive exam, and medical decision 
making of high complexity. The procedure report does not include a comprehensive exam or medical decision 
making of high complexity. The CPT code at issue cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for initial hospital care (99223) billed for date of service January 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on April 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that services were provided to the enrollee out of 
medical necessity, and you would like the claim reprocessed. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 the podiatry services provided on April 15, 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 debridement of nails provided on January 5, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the debridement. You say that the doctor should not be penalized for the hospital 
staff's failure in taking proper steps to obtain authorization. The Plan denied your request. The Plan says the 
provider is out-of-network with the Plan and authorization was not obtained prior to services being rendered. 
 
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 the debridement of nails provided on January 5, 
2022, by an out-of-network provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to reimburse you for the 6 over-the-counter (OTC) coronavirus tests purchased on 
January 20, 2022. 
 
You asked the Plan to reimburse you for the 6 OTC coronavirus test. You say that at the time the test was 
purchased, coronavirus cases were rampant. You say that testing sites were very busy. You say that you were 
more comfortable testing at home. You also say that these should be covered. The Plan denied your request. 
The Plan says that the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 6 OTC coronavirus test have been met. Specifically, the file shows that the OTC tests were 
purchased after January 15, 2022. Therefore, we decided that the Plan has to reimburse you for the 6 over-the-
counter (OTC) coronavirus tests purchased on January 20, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the echocardiography (93313) provided on February 4, 2022. 
 
You asked the Plan to pay for the echocardiography (93313). You say that CPT code 93313 is separately 
payable and diagnosis code I50.21 is approved per LCD guidelines. You say that the attached anesthesia 
records show medical necessity and code 93313 should be reprocessed for payment. The Plan denied your 
request. The Plan says that CPT code 93313 is included in CPT code 00567 and cannot be separately 
reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93313 
is a column II code to column I code 00567; however, 93313 was billed with a modifier. 
 
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 echocardiography (93313). Our reviewer says that the 
medical documentation supports the use of the modifier used with procedure code 93313. Our reviewer found 
procedure code 93313 does have an edit with 00567, but you may override the edit with an associated modifier 
when appropriate. 
 
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 echocardiography (93313) have been met. Therefore, we decided that the 
Plan has to pay for the echocardiography (93313) provided on February 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker rendered on June 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Therefore, we 
decided that the Plan does not have to pay for the walker rendered on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital visit on February 11, 
2022. 
 
You asked the Plan to waive the copayment for outpatient hospital visit. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost-sharing you are 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). Your contract with the Plan clearly says that you must pay a $165 
copayment for each Medicare-covered outpatient admission to an outpatient hospital facility. The provider 
billed in the amount of $527 and the Plan paid $483.96. Therefore, resulting in the total cost-sharing amount of 
$43.04, which is less then the copayment amount.  
 
 
 
 You have been asked to pay a $43.04 copayment for outpatient hospital visit. Outpatient hospital visits fall 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 outpatient hospital visit on 
February 11, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from February 4, 2022, through March 
5, 2022. 
 
You asked the Plan to pay for home health services. You say that this is a 2022 claim and an NOA is required 
not a RAP. You say that the NOA was accepted, and the claim should be processed correctly. The Plan denied 
your request. The Plan says that the RAP is required to process the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have been met. Specifically, the rules cited by the Plan regarding a Request 
for Anticipated Payment have been superseded as of January 1, 2022. An NOA is only required for the first 
episode of care, and this is the second episode of care after this rule went into effect. Therefore, we decided that 
the Plan has to pay for home health services provided from February 4, 2022, through March 5, 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 Tempus xT Heme Panel rendered on November 12, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific 
criteria 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has thrombocytopenia most 
likely associated with cirrhosis. The record provided suggests that the requested test exceeds the clinical needs 
of the enrollee. The testing was 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 pay for the Tempus xT Heme Panel rendered on November 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 22, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you and 
the emergency medical service (EMS) was called, but you had been helped up by the time the ambulance 
arrived, and you no longer needed transport. You also say that the EMS did not treat you at all, and you feel 
you should not be responsible for these charges. The Plan denied your request. The Plan says this service is not 
approved. 
 
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 October 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PancraGEN testing provided on June 1, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in the absence of provider records and/or abnormal cytology tests, there is no evidence to support 
that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the 
enrollees condition(s). 
 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PancraGEN testing provided on June 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 26, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Hospice is the 
primary payer for this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on January 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgical visits provided from 
January 4, 2022, to March 15, 2022. 
 
You asked the Plan to waive the copayments for outpatient surgical visits. You say that your copayment for the 
same services in 2021 was $45, so this seems unfair. The Plan denied your request. The Plan says the 
copayment amounts you are being charged are 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). Your contract with the Plan clearly says that you must pay $290 
copayment for each in-network outpatient hospital facility visit. There were 10 visits, resulting in a total 
copayment amount of $2,900. 
 
You have been asked to pay $290 copayment for each outpatient surgical visit. Outpatient surgical visits fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 outpatient surgical 
visits provided from January 4, 2022, to March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 the laboratory services provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the criteria 
established in the applicable LCD. 
 
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 injections. Our reviewer says that 
the requested RFA is not medically reasonable and necessary. Our physician reviewer found that the first 
injection provided only 50% pain relief. The requested facet joint injections are not medically reasonable or necessary according to the coverage criteria established in the LCD. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on July 6, 2021, to July 7, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that the criteria for an inpatient admission has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was not medically stable for discharge until July 10, 2021. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on July 6, 2021, to July 7, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services (99232) provided on 
May 13, 2019, and May 15, 2019. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that four claims were initially sent 
timely, but only one claim was paid for. You also say that you would like these claims to be processed and 
paid, as they were sent at the same time. The Plan denied your request. The Plan says your claim has been 
denied correctly by the health Plan due to untimely submission of the initial claim. The Plan also says that no 
valid proof of timely filing has been submitted. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent hospital care services was not filed until February 10, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services (99232) 
provided on May 13, 2019, and May 15, 2019.