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

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 15, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that this procedure was significant and 
separately identifiable.  You say that this service was medically necessary and should be paid. The Plan denied 
your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 88291 provided June 30, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review attached documentation for 
further payment for services billed. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 12, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 88291 provided 
June 30, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 6, 2022, to February 4, 
2022. 
 
You asked the Plan to pay for the home health 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 as billed. 
 
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 file includes a Notice of Admission (NOA) and there is no indication of a 
discrepancy between the dates of service at issue. The Plan has not clearly stated why these claims are not valid 
with supporting evidence based on Medicare payment guidelines. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plans denial is not substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for the home health services provided from January 
6, 2022, to February 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 24, 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 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. 
 
The testing at issue in this appeal, a comprehensive pharmacogenetics panel and comprehensive cardio panel, 
was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth service provided on July 15, 
2022. 
 
You asked the Plan to waive the copayment for the telehealth service. You say that the copayment for a 
specialist visit should be lower 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 $30 
copayment for each Medicare-covered specialist visit. Telehealth services will apply the copay appropriate to 
the type of provider consulted. 
 
You have been asked to pay a $30 copayment for the telehealth service. This item/service falls within the each 
Medicare-covered specialist visit. Telehealth services will apply the copay appropriate to the type of provider 
consulted 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 telehealth service 
provided on July 15, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from August 30, 
2021, to August 31, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the enrollee's care could have been continued in observation 
status. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee had a neurology consultation on 8/29/2021 with a recommendation to undergo 
a lumbar puncture. There was a delay in performing the lumbar puncture until 8/30/2021. The enrollee's 
symptoms improved status-post lumbar puncture and administration of Diamox and he was discharged home 
on 8/31/2021. The review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from August 30, 2021, to August 31, 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 an office visit provided on May 23, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you were misinformed by your enrollment advisor 
which resulted you in receiving out-of-network care. 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 May 23, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 28, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that the services were rendered in good faith and were 
medically necessary. You say the provider depends on the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance. 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 April 28, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 18, 2021, billed 
with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191, and 
81309. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 18, 2021, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 
81401, 81301, 81191, and 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the claim is for COVID-19 testing and it should be 
covered by the Plan. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no referral from an in-network provider or an approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 1, 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 anesthesia services provided on May 30, 2021. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for anesthesia services provided on May 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services billed with code A0429-RW for date of 
service May 27, 2022. 
 
You asked the Plan to pay for code A0429-RW. You say that you are an ET3 provider and the RW 
origin/destination modifier is appropriate. The Plan denied your request. The Plan says you billed with an 
incorrect origin/destination modifier for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the RW origin/destination modifier is only 
allowable for ET3 claims.  In addition, ET3 model rules only apply to Medicare Fee-For-Service beneficiaries.  
The enrollee in this case is not a Medicare Fee-For-Service beneficiary.  Instead, they are a Medicare Advantage enrollee.  The ET3 model payment rules do not apply in this case.  As a result, the treatment in 
place (i.e., W) destination portion of the modifier is not correct. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code A0429-RW have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance services billed with code A0429-RW for date of service May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on May 06, 
2022. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you went to the urgent care 
and was not tested for the coronavirus (COVID-19). 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 $55 
copayment for urgently needed services. 
 
You have been asked to pay a $55 copayment for urgent care services. This item/service falls within the 
urgently needed 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 urgent care 
services provided on May 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit and visual field examination 
provided on March 24, 2022. 
 
You asked the Plan to waive the copayment for office visit and visual field examination. You say that the cost-
share for specialist level 1 visit is $15 instead $35. 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 $35 
copay for physician/practitioner services, including doctors office visits and $75 copayment for outpatient 
diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay $35 copay for office visit and $40, which is less than the $75 copayment for visual 
field examination. These items/services fall within the physician/practitioner services, including doctors 
office visits and 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 office visit and visual field examination provided on March 
24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
09, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were supporsed to 
have your results read to you, and they were not in the office. You also say that five minutes before the 
appointment ended, the results were found. 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 $50 
copayment for a specialist visit for Medicare-covered services. 
 
You have been asked to pay a $50 copayment for a specialist office visit. This item/service falls within the a 
specialist visit for Medicare-covered 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 a specialist office visit provided on June 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard wheelchair (K0001) provided February 28, 
2022. 
 
You asked the Plan to pay for the wheelchair. You say that We would like to have the denial overridden and 
the claim reviewed for payment with the attached supporting documentation, which shows that the supplies 
were medically necessary and were provided to the enrollee' under a physician's prescription. The Plan denied 
your request. The Plan says the services is not covered by Medicare. 
 
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 find that CPT code K0001 is not supported in the medical record. Specifically, the capped 
rental period of 13 months for this item has been exceeded. Once the 13th month of rental ends, the supplier 
must transfer ownership of the equipment to the enrollee. You can find this information in Medicare Coverage 
of Durable Medical Equipment & Other Devices https://www.medicare.gov/media/publication/11045- 
medicare-coverage-of-dme-and-other-devices.pdf Based on this information, we decided that Medicare rules 
for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for 
the standard wheelchair (K0001) provided February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig provided on May 27, 2022. 
 
You asked the Plan to pay for the wig. You say that you are a cancer patient receiving chemotherapy and you 
have lost all of your hair due to chemotherapy treatment and you were prescribed a script for a wig. The Plan 
denied your request. The Plan says the services are not covered under the members contract under any normal 
circumstances. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is non-covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig provided on 
May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 6, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you are appealing with 
supporting records. 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 $50 
copayment for each specialist or any other physician or other health care professional visit for Medicare-
covered benefits in a specialist setting.  
 
 
  You have been asked to pay a $50 copayment for a specialist office visit. This item/service falls within the 
specialist or any other physician or other health care professional visit for Medicare-covered benefits in a 
specialist setting 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 a specialist office 
visit provided on May 6, 2022.