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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
25, 2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 25, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for treatment from phase 1 clinical trials provided from April 1, 2021, to 
November 30, 2021. 
 
You asked the Plan to pay for treatment from phase 1 clinical trials. You say that you are appealing any and all 
charges for treatment from April 1, 2021, to November 30, 2021, for phase 1 clinical trials. The Plan denied 
your request. The Plan says that the claims were denied for non-contracted provider performing contracted 
services. The Plan said that they did not provide the enrollee with a decision within 60 days after receiving the 
standard reconsideration request. 
 
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. The Plan failed to confirm the correct dates of service that are being appealed by 
the enrollee, and the Plan also failed to provide an explanation of benefits/remittance form for the dates of 
services. Therefore, we decided that the Plan has to pay for treatment from phase 1 clinical trials provided from 
April 1, 2021, to November 30, 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 the laboratory services rendered on June 5, 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 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, a cardiovascular risk assessment panel, 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 the laboratory services rendered on June 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 28, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on June 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
September 1, 2021, to September 9, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you thought if you were an 
inpatient then Medicare would be billed. 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 $325 per 
day for days 1-5 and $0 per day after day 5 for each inpatient stay.  
 
The file shows that you were in the hospital from September 1, 2021, to September 9, 2021. Therefore, you 
have been asked to pay $325 per day for the first 5 days of inpatient care. The total for your stay is $1,625 ($325 copayment x 5 days = $1,625). The inpatient care falls within the Inpatient Hospital 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 inpatient hospital care provided from 
September 1, 2021, to September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nasopharyngoscopy, surgical, with 
dilation of the eustachian tube (69705) provided on June 7, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $225 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.    
You have been asked to pay a $225 copayment for the Medicare-covered surgery provided at an outpatient 
hospital. 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 nasopharyngoscopy, surgical, with dilation 
of the eustachian tube (69705) provided on June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that you do not meet criteria for these services. 
 
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 pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You have psychosis, 
diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), asthma and presented 
to the hospital with confusion, hypoglycemia, and was found to have a urinary tract infection (UTI).  You were also diagnosed with hypo-osmolality and hyponatremia. You were treated with antibiotics and fluids. 
It was noted that you had confusion at baseline and used oxygen at home (3L) at baseline for chronic lung 
disease. You were afebrile and had no leukocytosis. Based on the provided documentation, you appeared stable 
and near baseline, responding to initial treatment from the emergency department and had not failed outpatient 
treatment. There was no suggestion that you would require hospital services that would likely cross 2 midnights 
in duration. Our physician reviewer found that your condition does not meet criteria for inpatient hospital 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 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 procedure code G0483 is not 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
 
 
 
 We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation 
of results for 22 or more drug classes. 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 drug 
testing rendered on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physician's services provided on 
October 20, 2020. 
 
You asked the Plan to waive the copayment for the physician's services. You say that you should not be 
responsible for the copayment amount. The Plan denied your request. The Plan says the provider confirmed 
paperwork and documentation was completed so the enrollee could be eligible for home health services. 
Therefore, the proper copayment was applied. 
 
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 a specialist physician consultation your doctor has with other physicians via telephone, internet, 
or electronic health record assessment  if you are an established patient.  
 
  You have been asked to pay a $40 copayment for the physician's services. The physician's services falls within 
the Physician/Practitioner services, including doctors office visits 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 physician's services provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 18, 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 testing is not billed correctly. 
 
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 these 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 rendered on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on May 24, 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 procedure code 99152 is not 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 99152 is moderate sedation services by other qualified 
health care professional requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to monitor the enrollee's level of consciousness and physiological status for the 
first 15 minutes. 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 moderate sedation services 
rendered on May 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425 and A0428) provided on July 
6, 2021. 
 You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the 
enrollee was not inpatient on the billed date of service. The Plan denied your request. The Plan says the 
enrollee was registered inpatient on the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient, is covered under the prospective payment 
rate.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the documentation indicates that the 
enrollee was registered inpatient on the billed date of service. Payment for this transportation service is 
included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we 
decided that the Plan does not have to pay for the ambulance services (A0425 and A0428) provided on July 6, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care. The documentation notes the enrollee has wounds but there is no detailed information on 
these wounds and the 4/21/22 integumentary exam notes "warm, pink, dry." The enrollee does not need skilled 
nursing care in a SNF for her PEG feedings or other skilled nursing need. The enrollee is unable to participate 
in therapy due to her cognitive status currently. The enrollee's functional level does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing 
or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter, the 
enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided on July 13, 2021. 
 
You asked the Plan to pay for physician services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 7, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for physician services (99232) 
provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital facility charges provided on 
September 14, 2021. 
 
You asked the Plan to waive the copayment for the hospital facility charges. You say that it is your 
understanding that all care prescribed and received in-network under your plan is covered or just a copayment, 
but this claim appears to be determined as coinsurance instead. You also say this treatment should be covered 
in full by your insurance plan. 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 other in-network medical services provided at an outpatient hospital including hospital or other 
facility charges. 
 
You have been asked to pay the allowed amount of $106.86, which is less than the $295 copayment for hospital 
facility charges. Hospital facility charges falls within the Outpatient Surgery and Other Medical 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 the hospital facility charges provided on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the office visit (99213) provided on January 6, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that you were told this provider was in-
network, and you do not understand why you are being billed $85. The Plan denied your request. The Plan says 
that this claim was processed correctly, as you have a $233 deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for office visits with a primary care 
provider or specialist. The contract makes no mention of a required deductible for any services. 
 
The Plan says you must pay a deductible for the office visit. Based on the Plan contract, however, you cannot 
be asked to pay more than a $0 copayment for the office visit. Therefore, we decided that the Plan has to waive 
the deductible for the office visit (99213) provided on January 6, 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.