Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on March 15, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on March 
15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of abdomen (74019) provided on March 4, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the x-ray of abdomen (74019) provided on March 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic procedures provided on June 
2, 2022, and June 16, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic procedures. You say that each scheduled test was 
a screening test and should be 100% covered. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. Also, both tests were diagnostic test, and they were not billed as preventative test. 
 
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 $300 
copayment for each Medicare-covered outpatient hospital service, including observation, outpatient surgery or 
procedure. For each date of service, a $300 copayment was charged for the diagnostic test. The total copayment 
amount for both dates was $600 ($300 copayment + $300 copayment). 
 
  You have been asked to pay a $600 copayment for the diagnostic procedures. 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 the 
diagnostic procedures provided on June 2, 2022, and June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stab phlebectomy provided to the enrollee on July 18, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was denied due to a lack of medical necessity for the service. 
 
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 pay for the services. Our reviewer says that the 
requested /services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as no time was given between the saphenous vein ablation and the stab phlebectomy to reassess, 
from the standpoint of the stab phlebectomy, the patient could not be considered symptomatic and not 
considered to have trialed conservative therapy. The health plan does not provide for simultaneous treatment of 
saphenous reflux and tributary treatment.  A rationale for this is that many patients will have satisfactory 
improvement in their symptoms with saphenous ablation alone and tributary treatment in that case would be 
unnecessary. There is no documentation of a unique feature of this patients condition that would necessitate 
proceeding outside health plans coverage guidelines.   
 
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 a stab phlebectomy provided to the enrollee on July 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the hospital observational care services provided June 
13, 2022. 
 
You asked the Plan to waive the copayment for the hospital services. You say that you are being told you are 
responsible for $478.66. As of today, you have not received a bill on this amount. You are on a fixed income 
and cannot just pay something without a bill. Please reconsider your claim. The Plan denied your request. The 
Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
You have been asked to pay $478.66 for the hospital services. Based on the Plan contract, however, you cannot 
be asked to pay more than $0.00 for the hospital services. The allowed amount per the enclosed Explanation of 
Benefits was $0.00. The Plan has not provided any supporting or clarifying information for applying a cost-
share to a claim with $0 allowed amount for the total claim. The Plan also has not provided any breakdown to 
support a cost share of $478.66. Therefore, we decided that the Plan has to waive the copayment for the 
hospital observational care services provided June 13, 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 pay for the Shingles vaccine provided on February 4, 2022. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you do not know why this is not covered. The 
Plan denied your request. The Plan says the Shingles vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine provided on 
February 4, 2022.  
 
Benefits for the Shingles vaccine 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) testing (0037U) provided on 
April 28, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and was provided 
for a covered indication. The Plan denied your request. The Plan says there is insufficient information in the 
submitted records to find this service medically necessary. 
 
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. The rules say that while a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent for the testing to be performed. Tests 
which are not ordered by the physician who is treating the enrollee are not reasonable and necessary. 
 
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 F1CDx testing have been met. 
Specifically, no progress notes or physician order were submitted to show that these services were medically 
necessary and ordered by the enrollees treating physician. Therefore, we decided that the Plan does not have to 
pay for FoundationOne CDx (F1CDx) testing (0037U) provided on April 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency ambulance transportation 
(A0429) provided on June 10, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that your doctor told you to 
go to the hospital because your oxygen level was low. 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 $250 
copayment for ambulance services.  
 
 
 You have been asked to pay a $250 copayment for ambulance transportation. This service falls within the 
ambulance 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 emergency 
ambulance transportation (A0429) provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service August 5, 
2021. 
 
You asked the Plan to pay for procedure code 99214. 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 99214 is bundled into 
payment for code 77263. 
 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 99214 
is a column II code to column I code 77263. 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 99214 billed for date of service August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for acute rehabilitation provided on June 21, 
2022, to July 1, 2022. 
 
You asked the Plan to waive the copayment for the acute rehabilitation. You say that you feel this should be 
covered because you are on a fixed income and this copay is way too high for you. You say that you don't have 
the extra money to pay for this. 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 $275 
copayment each time you are admitted to an acute care hospital, you pay $275 per day for days 1-5 and $0 after 
day 5. This applies to all admissions, including a transfer from another facility such as and acute rehabilitation 
or skilled nursing.  
 You have been asked to pay a total of $1,375 ($275 copayment x 5 days = $1,375). This item/service falls 
within inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for acute 
rehabilitation provided on June 21, 2022, to July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on August 16, 2021. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not 
support 22 or more drug classes were tested on August 16, 2021. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0483 have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing (G0483) provided on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81225, 81227, 81230, 81231, 81232, 81306, 
81328, 81355, 81335, 0031U, 0032U, and 0033U) provided on April 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 the lab services (81225, 81227, 81230, 81231, 81232, 81306, 81328, 81355, 
81335, 0031U, 0032U, and 0033U) provided on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware the provider was not 
contracted with the Plan. The Plan denied your request. The Plan says an authorization was not submitted prior 
to services rendered. 
 
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 laboratory services provided on May 13, 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 (G0480, 80307) provided on March 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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 (G0480, 80307) provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided from January 24, 
2022, to March 7, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you cannot afford to pay all of the 
coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for injections. The total allowed amount is $18,804.27 
(18,804.27 x 20% = $3,760.85). However, you are only being asked to pay $3149.72 which is less than the 
required amount. 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 coinsurance for injections provided from 
January 24, 2022, to March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PET scan provided on May 20, 2022. 
 
You asked the Plan to waive the copayment for PET scan. You say that you shouldnt have to pay for this. 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 $325 
copayment for Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $325 copayment for PET scan. This item/service falls within the Medicare-
covered diagnostic radiology 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 
PET scan provided on May 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network mental health visits 
provided on September 23, 2021. 
 
You asked the Plan to waive the copayment for out of network mental health visits. You say that you were told 
there would be no charge for this. 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 Outpatient mental health care. 
 
You have been asked to pay a $55 copayment for out of network mental health visits. 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 out of network mental health visits provided on September 23, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for injection services (procedure code 62326) provided to the enrollee on 
June 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 62326 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 62326 is "Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, 
of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not 
including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without 
imaging guidance." 
 
We asked our coder 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 the services at issue in 
this case were supported by the medical records. Our reviewer found that this patient had a robotic laparoscopic 
colectomy. A spinal dose of medication was administered for post-operative pain control. A consultation from 
the surgeon for post-operative pain control was made. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
injection services (procedure code 62326) provided to the enrollee on June 26, 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.