Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for pneumatic compression device appliances provided on November 18, 
2021. 
 
You asked the Plan to pay for pneumatic compression device appliances. You say that the place of service code 
for this product should rightfully be 12. The Plan denied your request. The Plan says that the denial of payment 
for these items is correct, because an invalid place of service code was used for this equipment. 
 
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 rules say that coverage for DMEPOS items is considered for certain place of service codes. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit a copy of the original claim form submitted for this 
claim. The Plan states that an invalid place of service (POS) code was billed on this claim. Without a copy of 
the claim form submitted to the Plan, we cannot determine whether the POS code billed is valid or invalid for 
DMEPOS items. Therefore, the Plan has not shown that its decision to deny payment for this equipment is 
correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for pneumatic 
compression device appliances provided on November 18, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on September 8, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient surgery. You say that you are requesting a reconsideration. 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 outpatient surgery provided on September 8, 2021, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiac screening services (81403, 81401, 81404) 
provided December 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting a redetermination of the 
denial and have enclosed documentation to substantiate the claim. The Plan denied your request. The Plan says 
screening genetic testing is not a covered benefit.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for hereditary cardiac screening services (81403, 81401, 81404) provided December 16, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 1, 
2020. 
 
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 claim was not filed timely. 
 
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 these services was not filed until April 5, 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 emergency room (ER) services rendered on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the global fee urgent care services 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 We find that CPT code S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9083 is not valid for Medicare purposes. 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 
global fee urgent care services rendered on November 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the psychotherapy services (90832) provided on November 10, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have been met. Specifically, the record shows that the enrollee was 
referred to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay 
for the psychotherapy services (90832) provided on November 10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional x-ray services provided to the enrollee on 
November 28, 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 submitted do not indicate that two separate services were performed and supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 71045 is "Radiologic examination, chest; single view." 
 
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 a single one-view chest x-ray was 
done on 11/28/21, and signed by the doctor at 7:09. There is no additional exam for that date in the records. 
 
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 additional x-ray services provided to the enrollee on November 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 12, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that there was no life 
support given or needed during the trip. 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 $295 
copayment for each one-way ambulance trip.  
 
 
 
 
 
 
 You have been asked to pay a $295 copayment for the ambulance 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 copayment for 
ambulance transportation provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 1, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan has requested an EOB from the primary insurance and the provider's office multiple times and has not 
received it. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the EOB. As the secondary insurer, the Plan cannot be held responsible for the physician's services until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for physician's services provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement services and rest home visit (11721, 
99324) provided on March 25, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound debridement services and rest home 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 wound debridement services and rest home visit 
(11721, 99324) provided on March 25, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for onabotulinumtoxina injections provided 
from April 2, 2021, to February 4, 2022. 
 
You asked the Plan to waive the coinsurance for the onabotulinumtoxina injections. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for 4 onabotulinumtoxina injections (total allowed is $4,771.47 
x 20% = $954.3). Onabotulinumtoxina injections fall 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. Therefore, we 
decided that the Plan does not have to waive the coinsurance for onabotulinumtoxina injections provided from 
April 2, 2021, to February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary home visit provided on January 4, 2022, by an 
OON provider. 
 
You asked the Plan to pay for a domiciliary home visit. You say that the providers rely on facility staff to 
verify eligibility and obtain authorization from the enrollee's plan. 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 domiciliary home visit provided on January 4, 
2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 11, 2021, 
through October 21, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the inpatient 
hospital care provided was not medically necessary. 
 
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 the 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 that the enrollee was brought to the hospital on October 11, 2021 for a trauma 
response following a mechanical fall at home. She was later discharged when considered medically stable on 
October 21, 2021. The review has determined that the record showed that at the time of the inpatient admission 
the admitting physician reasonably expected that the enrollees necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from October 11, 2021, through October 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on October 28, 
2021. 
 
You asked the Plan to pay for the services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says payment is not allowed for this service because it is not appropriate for the 
codes 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 00811 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified." 
 
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 due to the lack of intraoperative 
anesthesia records submitted, along with the lack of a diagnosis and surgical procedure note, the reviewer is 
unable to assess any requirements for the billed CPT code 00811-QX-P3, provided by a certified registered 
nurse anesthetist (CRNA) and an MD anesthesiologist.  The records in this case do not support that CPT 00811 
was billed correctly. 
 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 anesthesia services provided to the enrollee on October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for outpatient lab services. You say that you have never had a 
copayment for lab services with this Plan before. The Plan denied your request. The Plan says the copayment 
applied was 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 $50 
copayment for Medicare-covered lab services in an outpatient hospital setting.  
 
You have been asked to pay a $50 copayment for lab services. Lab services falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 lab services provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on 
January 24, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home 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 the domiciliary or rest home visit (99336) 
provided on January 24, 2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the PT visit provided on January 20, 2022. 
 
You asked the Plan to waive the copayment for the PT visit. You say that you refuse to pay any portion for the 
service. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each in-network Medicare-covered physical and speech therapy service.  
 
 
 
 
 
 
 
 You have been asked to pay the allowed amount of $28.82 for the PT visit, rather than then standard $40 
copayment. The PT visit 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 the physical therapy (PT) visit provided on January 20, 2022.