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 November 23, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services rendered on November 11, 2021 to 
November 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
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. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 outpatient services rendered on November 11, 2021 to November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation does not 
support that you require additional skilled rehabilitation services to provide treatment that is medically 
necessary. You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
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 records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a rolling walker with contact guard assistance and is stand-by assist for transfers. 
Provided records do not document a significant decline in the enrollees functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not document that services in the home with home health care or in 
a long-term care facility on a part time basis are not appropriate in this case. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided September 3, 2021. 
 
You asked the Plan to pay for the initial hospital care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, initial hospital care (99223) 
was billed on the same day as hospital discharge management (99239). There is a more appropriate CPT to use 
when the patient is discharged the same day as admission. Based on this information, we decided that Medicare 
rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (99223) provided September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (62320) provided December 6, 2021. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of injections (62320) provided December 6, 2021. have been met. Only a procedure note was provided. No office notes to support medical necessity 
were included. The provided records were not signed. The plan requested additional records and none were 
provided. Therefore, we decided that the Plan does not have to pay for injections (62320) provided December 
6, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for surgical services and medical supplies provided 
December 20, 2021. 
 
You asked the Plan to waive the coinsurance for the surgical services and medical supplies. You say that 
payment for these items should have been included in the inpatient stay and you should not be liable for 
coinsurances. The Plan denied your request. The Plan says that the correct cost-sharing was applied. 
 
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 IRE requested additional information from the plan, including the plan 
denial letter, and no new information was provided. The plan has not clearly articulated the denial. It is not 
clear from the documentation provided which services are being denied. Therefore, we decided that the Plan 
has to waive the coinsurance for surgical services and medical supplies provided December 20, 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 waive the copayment for the injection(s), of a diagnostic or 
therapeutic agent, of the paravertebral facet joint with image guidance (64493) provided on April 19, 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 $350 per day for other outpatient procedures and 
services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed 
in an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay $350 for the outpatient procedure provided in 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 injection(s), of a diagnostic or therapeutic agent, of the 
paravertebral facet joint with image guidance (64493) provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the spherocylinder, single vision, 
plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder (V2103) and prism, per lens (V2715) provided 
October 27, 2021. 
 
You asked the Plan to provide additional payment for the routine eyewear lenses. You say that you would like 
the eyewear to be covered. The Plan denied your request. The Plan says your $200 allowance has been applied 
to your routine eyewear and no further payment is due. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $200 allowance. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that the $200 allowance 
was applied to your claim. Therefore, we decided that the Plan does not have to provide additional payment for 
the spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder (V2103) and 
prism, per lens (V2715) provided October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81227, 81230, 81240, 81241, 81291, 81355) 
provided September 21, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single genetic testing 
panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81227, 81230, 81240, 
81241, 81291, 81355) provided September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81345) provided October 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code at issue shares a bundled relationship with another code billed and 
is not eligible for separate payment.  
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 81345 
is a column II code to column I code 0089U. 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 lab services (81345) provided October 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 30, 2021, to August 1, 2021. 
 You asked the Plan to pay for the services. You say that this was denied in error. The Plan denied your request. 
The Plan says the enrollee did not require daily skilled nursing services such as the administration of IV 
antibiotics, management and education of a new PEG tube or colostomy, or complex wound care. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the patient required skilled nursing services or skilled therapy services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist were not 
required to safely and effectively provide medically necessary and reasonable treatment from 07/30/2021 
through 08/01/2021. The records did not document the need for intravenous medications, new tube feeding or 
ostomy care or daily complex wound care. Daily skilled services were not required. No physical therapy or 
occupational therapy assessment were performed during the period at issue. This patient did not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear 
custodial in this case from 07/30/2021 through 08/01/2021. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 30, 2021, to August 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on December 13, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
December 13, 2021 have been met. The Health Plan has not received the required clinical records to support 
the medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does 
not have to pay for an epidural injection provided on December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (S9999) provided on May 24, 2021 by 
an out-of-network provider. 
 
You asked the Plan to pay for the wound care supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says medical equipment obtained from non-contracted providers is non-
covered. 
 
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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for wound care supplies (S9999) provided on May 24, 2021 by an out-of-network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine gynecology visit (G0101) provided June 23, 2021. 
 
You asked the Plan to pay for the gynecology visit. You say that this visit was medically necessary as your 
previous exam was abnormal. The Plan denied your request. The Plan says the benefit for this service was 
exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that  medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services 
include services to improve the functioning of a malformed body member. This service is a preventative 
service. The plan's rules apply in this case. The plan provides coverage for 1 routine gynecological exam every 
24 months. 
 
We looked at the file and Medicare rules. The enrollee had a previous exam on March 5, 2020. The record from 
this exam shows no abnormal findings. An additional exam is not covered under the benefit. Based on this information, we decided that Medicare rules for coverage of the gynecology visit have not been met. Therefore, 
we decided that the Plan does not have to pay for a routine gynecology visit (G0101) provided June 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (H2017) provided on 
October 25, 2021 to October 28, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there were network providers available. The services 
were not pre-authorized 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 services at issue in this appeal. The Plan did not pre-approve the service 
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 outpatient mental health services (H2017) provided on October 25, 2021 
to October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (62320) provided December 20, 2021. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says insufficient records were provided to support this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of injections (62320) provided December 20, 2021. have been met. Only 2 pages of records were provided. This included only a procedure note. No 
office visit notes were provided to support medical necessity of this service. Additional records were requested 
and none were provided. Therefore, we decided that the Plan does not have to pay for injections (62320) 
provided December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81403, 81404, 81406, 81407) provided May 4, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81403, 81404, 81406, and 81407 are not supported in the medical record. Specifically, 
the same codes were already billed on the same date of service and were approved and paid under claim 
number 820212460140317. This claim is a duplicate. Additional units are not supported. 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 lab services (81403, 81404, 81406, 81407) provided May 4, 
2021.