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

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 22, 2022. 
 
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. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82947, 81015, and 80050 billed for date of 
service May 20, 2020. 
 
You asked the Plan to pay for procedure codes 82947, 81015, and 80050. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 82947 is 
bundled into payment for code 80053 and payment for code 81015 is bundled into payment for code 81000. 
Additionally, code 80050 is not covered by Medicare or the Plan. 
 
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 82947 is a column II code to column I code 80053. This claim has 
not been billed with an appropriate modifier to bypass the edit. We have also confirmed that code 81015 is a 
column II code to column I code 81000 with a modifier indicator of 0. The column II code is therefore not 
payable. Finally, you have requested payment for services billed under code 80050. Medicare does not cover or 
pay for services billed under this code. 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 codes 82947, 81015, and 80050 
billed for date of service May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 71250 is bundled into payment for code 71275. 
 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 71250 
is a column II code to column I code 71275. 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 71250 billed for date of service May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and Part B drugs provided on 
May 10, 2022. 
 
You asked the Plan to waive the cost share for an office visit and Part B drugs. You say that you never had to 
pay so much in the past. The Plan denied your request. The Plan says the cost share applied 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 20% 
coinsurance for Medicare covered Part B drugs and $40 copayment for each specialist visit.  
 
 
 
 You have been asked to pay $148.97 which is 20% of the allowed amount for Part B drugs The allowed 
amount is $744.84 (20% x $744.84= $148.97). You have also been asked to pay $40 copayment for an office 
visit. The total amount you must pay is $188.97. Part B drugs falls within the Medicare Part B Prescription 
Drugs benefit category. The office visit falls within the Physician/Practitioner Services, Including Doctor's 
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 cost share for an office visit and Part B 
drugs provided on May 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 20, 2022, to February 2, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an NOA was 
not submitted within the correct time frame for this home health claim to be processed. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from January 20, 2022, 
to February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that the laboratory services are not supported in the medical record. Specifically, there is no 
documentation describing genetic testing on a sample collected on the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the construction and makeup of your 
bathroom, you cannot have grab bars installed. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22633, 22634, 22842, and 22853 billed for 
date of service December 16, 2021. 
 
You asked the Plan to pay for procedure codes 22633, 22634, 22842, and 22853. You say that the services 
were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. Since the primary procedure has been denied, the addon codes cannot be reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 22633 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Codes 22634, 22842, and 22853 are addon codes to this primary procedure. Since 
the primary procedure cannot be covered, the addon codes also are non-covered. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 22633, 22634, 22842, and 22853 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 22633, 22634, 22842, and 
22853 billed for date of service December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Part B drugs, computed tomography (CT) 
scan and outpatient surgery on January 18, 2022, to March 16, 2022. 
 
You asked the Plan to waive the cost sharing for Part B drugs, CT scan and outpatient surgery. 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 $1000 
deductible. You must pay a 20% coinsurance for all other Medicare-covered Part B drugs. You must pay $155 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). You must a $300 
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.  
 
On January 18, 2022, the allowed amount is $85.92. The full deductible was not met. The allowed amount of 
$85.92 was applied to the deductible. On February 14, 2022, to March 02, 2022, the allowed amount is $48.27. 
The full deductible was not met. There were 5 visits. $48.27 x 5 = $241.35. On February 25, 2022, the allowed 
amount is $66.89. This is less than the copayment amount. On March 16, 2022, the allowed amount is $48.27. 
This is less than the copayment amount. On February 23, 2022, the allowed is $1026.80, and 20% coinsurance 
of the allowed amount equals to $205.36. $85.92 + $241.35 + $66.89 + $48.27 + $205.36 = $647.79. 
Therefore, results in the total cost sharing amount of $647.79. 
 
You have been asked to pay $647.79 for Part B drugs, CT scan and outpatient surgery. Part B drugs, CT scan 
and outpatient surgery falls within the Medicare Part B prescription drugs, Outpatient diagnostic tests and 
therapeutic services and supplies, and 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 
cost sharing for Part B drugs, computed tomography (CT) scan and outpatient surgery on January 18, 2022, to 
March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 test purchased on April 25, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test. You say that a proctored negative COVID-19 test 
was required by the United States government at the time of purchase to enter the United States from an 
international destination. You also say this test was recommended by the travel company as the availability of 
local testing was not guaranteed. The Plan denied your request. The Plan says you took this COVID-19 test to 
travel internationally, and not for medically necessary needs or symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
 
 
 We looked at the file and Medicare rules. This testing was required by the government for the purposes of 
routine travel. Based on this information, we decided that Medicare rules for coverage of screening testing have 
not been met. Therefore, we decided that the Plan does not have to pay for at-home COVID-19 test purchased 
on April 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on March 30, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 March 30, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 18, 
2021, to February 16, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the RAP claim for services for dates of service January 18, 2021, to February 16, 2021, until December 
14, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 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 the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided from January 18, 2021, to February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received in-network. 
 
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 January 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2022 by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for 
services rendered to the enrollee. 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 an office visit provided on February 23, 2022 by 
an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that this is needed for anemia due to chemotherapy. The 
Plan denied your request. The Plan says Retacrit is not being requested for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Retacrit. Our reviewer says that the 
enrollee does not meet criteria for the requested use of Retacrit. Our physician reviewer found Retacrit is not 
Food & Drug Administration (FDA) approved for the enrollee's condition. The requested use is not supported 
by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Retacrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent antigen detection by immunoassay with 
direct optical (87811), sales tax (S9999), and shipping fees (A9270) provided on May 13, 2022.  
You asked the Plan to pay for the at-home COVID-19 test. You say that this test was required during travel to 
be able to return home. You also say that the Plan is required to cover the test. The Plan denied your request. 
The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by the airline for the purposes of routine 
travel. The Plan does not offer a supplemental benefit covering this service, as this is not currently required by 
Medicare. However, for future purchases, these can be obtained with participating providers and covered by 
Original Medicare when using your Medicare card rather than your Plan card. Based on this information, we 
decided that Medicare rules for coverage of screening testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the infectious agent antigen detection by immunoassay with direct optical 
(87811), sales tax (S9999), and shipping fees (A9270) provided on May 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for home health services. 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 it was 
determined these services can be received in-network. 
 
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 home health services provided on May 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the evaluating therapists recommend home with intermittent therapies thus IRF 
criteria have not been met and is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.