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

 
We decided that the Plan does not have to pay for a nursing facility visit provided on June 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility visit. You say that all services were medically necessary and 
provided at the request of the Skilled Nursing Facility/Primary Care Provider and that medical documentation 
substantiates the need for services/supplies and you ask for a review and consideration of all line items for 
reimbursement. The Plan denied your request. The Plan says there was no prior authorization submitted or 
approved for this service with an out-of-network provider. 
 
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 nursing facility visit provided on June 21, 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 copayment for hospital facility visits provided from June 
16, 2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for hospital facility visits. You say that you think the charge is too 
much money and no surgery. The Plan denied your request. The Plan says this cost sharing was charged 
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 $325 
copayment for outpatient hospital services.  
 
You have been asked to pay $325 copayment for each hospital facility visit. This item/service falls within the 
outpatient hospital 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 hospital 
facility visits provided from June 16, 2022, to July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 87640 is bundled into 
payment for code 87641. 
 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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
September 15, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing is 
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. 
 
We looked at the file and the rules. The testing services were requested for screening purposes. Medicare does 
not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
hereditary cardiovascular screening panel provided on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for inpatient hospital care provided from  
June 5, 2022, to June 13, 2022. 
 
You asked the Plan to reduce the copayment for inpatient hospital care. You say that because you were 
previously released from the hospital prematurely, you are now billing billed for 4 additional days instead of 2 
additional days. The Plan denied your request. The Plan says this cost sharing was charged 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 a $295 
copayment per day for days 1 to 4; $0 copayment per day, for days 5 to 90; $0 copayment for additional days 
for in-network inpatient hospital care. 
 
 You have been asked to pay $1180 ($295/day x 4 days = $1180) for inpatient hospital care. This item/service 
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 reduce the copayment for 
inpatient hospital care provided from June 5, 2022, to June 13, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81235) provided on September 27, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was not 
submitted with a covered diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that Local Coverage Article A52986 has established 
limited coverage for non-small cell lung carcinoma (NSCLC) molecular biomarkers (81235).  
 
We looked at the file and Medicare rules. Per A52986, the billed diagnosis codes, C80.1 and J90.1, are not 
covered for code 81235. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
(81235) provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair lift provided on May 10, 2022. 
 
You asked the Plan to pay for the stair lift. You say that you are unable to go up and down the stairs. The Plan 
denied your request. The Plan says stair lifts are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the stair lift provided on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64445 and revenue code 0637 billed for 
services provided from April 15, 2022, to April 16, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that code 64445 was not billed with a modifier suitable for 
payment. Revenue code 0637 indicates self-administered drugs. The self-administered drugs provided are not 
among the types which are covered by Medicare Part B. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 64445 and revenue code 0637 billed for services provided from April 15, 2022, to 
April 16, 2022.  
 
Benefits for the billed services may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 76700. The Plan denied your request. The Plan says payment for 
code 76700 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 76700 
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 76700 billed for date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that the enrollee changed her insurance and did 
not know you are not part of her network. You say you did not want the enrollee to go to the emergency room 
to get her medications and are appealing with supporting records. The Plan denied your request. The Plan says 
the enrollee must receive care from a network provider. 
 
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 psychotherapy services provided on February 2, 
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 May 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary and should be 
paid. 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 May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 provided on March 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Vive Rollator Walker you purchased on April 7, 2022. 
 
You asked the Plan to pay for the Vive Rollator walker. You say that you were told that this item would be 
covered at 100%.  You don't think you should be penalized for the provider's incorrect coding. The Plan denied 
your request. The Plan says that the code billed (A9901) has a status indicator of X on the Physician Fee 
Schedule, meaning that it is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that the code billed (A9901) 
has a status indicator of X on the Physician Fee Schedule, meaning that it is not separately payable. What the 
Plan has failed to recognize here is that the Vive Rollator Walker is an item of Durable Medical Equipment 
(DME) and would not be subject to the Physician Fee Schedule.  Rather, DME items are paid and priced on a 
separate fee schedule.  In addition, the Plan has failed to do a minimum of research on this issue.  A quick 
search of the Medicare DME Pricing, Data Analysis and Coding (PDAC) website shows that the code to be 
used for the Vive Rollator Walker is E0143. The Plan's reimbursement to you should have been based on the 
allowable amount for that code. Further, the Plan has failed to provide information regarding the Medicare 
contracting status of the DME provider from whom you received this item.  If the provider is a Medicare-
certified provider, they are only allowed to charge the Medicare-allowed amount for this item.  If the provider 
is NOT a Medicare provider, then the Plan (not you) is responsible for paying the difference in accordance with 
the Centers for Medicare and Medicaid Services, Internet-Only Publication 100-16, Medicare Managed Care 
Manual, Chapter 4, Section 170.2.  In either case, the Plan should have ensured that you were not responsible 
for any amounts above your contractually required cost sharing (if applicable.)  The Plan has failed to do so 
here. Therefore, we decided that the Plan has to pay for the Vive Rollator Walker you purchased on April 7, 
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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on 
July 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health care. You say that this was for your 
annual examination, and you should not have a copayment. The Plan denied your request. The Plan says this 
cost sharing was charged 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 in-network outpatient mental health care.  
 
 
 According to the 2022 EOC, a depression screening is covered once per year. The record shows you had a 
depression screening on April 4, 2022. You have been asked to pay $31.27 for outpatient mental health care, 
which is less than the standard $40 copayment. This item/service falls within the outpatient mental health 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 outpatient mental health care 
provided on July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vasectomy provided on March 1, 2022. 
 
You asked the Plan to pay for the vasectomy. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a vasectomy is non-covered if the primary 
indication is sterilization.  
 
We looked at the file and Medicare rules. The vasectomy in this case was provided for sterilization. Per NCD 
230.3, this is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of 
the vasectomy. have not been met. Therefore, we decided that the Plan does not have to pay for the vasectomy 
provided on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 14, 2021, to 
June 17, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were medically necessary and are supported in the record. The Plan denied your request. The Plan says 
DRG 871 is not appropriate as the diagnoses of sepsis, unspecified organism (A41.9) and acute respiratory 
failure with hypoxia (J96.01) are not supported in the medical record. The Plan argues that DRG 194 is more 
appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9) and acute 
respiratory failure with hypoxia (J96.01). 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that these diagnoses are not 
supported in the medical record for this inpatient admission. Our physician reviewer found the records show 
that the enrollee had pneumonia and elevated creatinine. There was no documentation of an elevated 
respiratory rate, hypotension, hypoxia, impaired liver function and/or documentation of impaired mentation. 
The enrollee's condition did not meet sepsis 3 criteria or the criteria for respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 14, 2021, to June 17, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 20, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70553. 
 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 70544 
is a column II code to column I code 70553. 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 70544 billed for date of service March 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FibroSURE testing. 
 
You asked the Plan to pre-approve FibroSURE testing. You say that this test is necessary to determine if the 
enrollee has fibrosis of the liver. A liver biopsy has a risk for complications and this testing is an appropriate, 
non-invasive option for patients with Non-Alcoholic Fatty Liver Disease (NAFLD). The Plan denied your 
request. The Plan says this testing is not definitively recommended as a first-line choice. It is considered 
experimental and investigational at this stage and therefore 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 pre-approve FibroSURE testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found assessment of liver fibrosis in the setting of established fatty liver is standard of care. 
The gold standard study is liver biopsy. Non-invasive options include advanced radiographic imaging, multiple 
elastographic techniques and serum panels. Many serum blood test assessments of liver fibrosis are non-
proprietary, readily available, and standardarized. FibroSURE is a propriety study for liver fibrosis assessment. 
While it is a stated preference of the enrollee's provider, it is not medically necessary in lieu of plan-preferred and covered non-invasive studies that are available to this enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FibroSURE testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve FibroSURE testing.