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

 
We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes, (99239) provided on December 10, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee did not show 
to have any other coverage on the date of service in this case. 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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes, (99239) provided on December 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 7, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for psychotherapy 
services have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on 
April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the codes billed are not 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that your primary care provider has prescribed Prolia. The 
Plan denied your request. The Plan says there is no information showing this medication is being administered 
at the provider's office and provided from the physician's stock. The Plan also says that this is not a buy and bill 
medication, and does not fall under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network (OON) specialist office 
visit and electrocardiogram (EKG) provided on March 7, 2022. 
 
You asked the Plan to waive the coinsurance for the OON specialist visit and EKG. You say that the provider 
should be in-network. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 35% 
coinsurance for specialist services with an out-of-network provider. 
 
Your contract with the Plan also clearly says that you must pay a 35% coinsurance for out-of-network diagnostic procedures and tests. 
 
Service Allowed Amount 35% Coinsurance 
Specialist Office Visit $129.54 $45.34 
EKG $6.22 $2.18 
Total:  $47.52 
 
The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a total of $47.52, which is 35% of the allowed amount for the OON specialist visit and EKG. The OON 
specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. The OON EKG falls within the 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 coinsurance for an out-of-network (OON) 
specialist office visit and electrocardiogram (EKG) provided on March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93880 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 93880. The Plan denied your request. The Plan says payment for 
code 93880 is bundled into payment for code 76536. 
 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 93880 
is a column II code to column I code 76536. 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 93880 billed for date of service April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Relion Prime test strips for the enrollee. 
 
You asked the Plan to pre-approve Relion Prime test strips. You say that the enrollee needs this because of 
Type 2 diabetes mellitus. The Plan denied your request. The Plan says that the enrollee does not meet criteria 
for coverage of a non-preferred diabetic supply. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file does not include any documentation documenting why the 
enrollee requires this specific brand of test strips. Without this, medical necessity cannot be established. 
Therefore, we decided that the Plan does not have to pre-approve Relion Prime test strips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for neurostimulator procedure on March 24, 
2022. 
 
You asked the Plan to waive the copayment for diagnostic services. You say that you already paid $30 for 
provider services but then you received another $30 charge for hospital services. 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 $30 
copayment for Medicare-covered non-radiological diagnostic services. Examples include, but are not limited to 
EKGs, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests. Covered services 
include but are not limited to other outpatient diagnostic tests - non-radiological diagnostic services. 
 
 
 
 You have been asked to pay a $30 copayment for diagnostic services. Diagnostic services fall within the 
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 neurostimulator procedure on March 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 26540) provided to the 
enrollee on October 8, 2021. 
 
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 the denied codes remain 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 26540 is "Repair of collateral ligament, 
metacarpophalangeal or interphalangeal joint." 
 
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 not supported by the medical records. Our reviewer found that the operative report describes 
proximal interphalangeal (PIP) joint radial collateral ligament (RCL) repair, and joint implant arthroplasty 
performed on the left small finger, same joint. In this case, repair of collateral ligament would be necessary to 
complete the more comprehensive procedure, which in this case is arthroplasty with prosthetic implant. Therefore, CPT 26540 would not be reported separately. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 26540) provided to the enrollee on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions received on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for these services. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 23, 2022. 
Therefore, we decided that the Plan does not have to pay for extractions received on March 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a magnetic resonance imaging 
(MRI) of a lower extremity provided on December 27, 2021. 
 
You asked the Plan to waive or reduce the copayment for the MRI. You say that if you knew the cost ahead of 
time you would have used a different facility. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $295 
copayment for diagnostic radiology services performed by a provider other than your PCP.  
 
You have been asked to pay $244.59, which is less than the $295 copayment for the MRI. The MRI falls within 
the 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 or reduce the copayment for a magnetic resonance imaging (MRI) of a lower extremity 
provided on December 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on April 29, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you want the Plan 
to pay for the services. The Plan denied your request. The Plan says if an ambulance responds to a call but does 
not transport the person for whom the call was placed, Medicare does not pay for the service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided to the enrollee from 
August 11, 2021, to August 24, 2021. 
 
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 the provider has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the review has determined that the records did not support the use 
of A41.89 - other specified sepsis - in this case. DRG 690 (KIDNEY AND URINARY TRACT INFECTIONS 
WITHOUT MCC) is the appropriate DRG. While the discharge summary listed a diagnosis of sepsis, the 
clinical evidence did not support assignment of the condition. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided to the enrollee from August 11, 2021, to August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 15, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 16, 2022, billed 
with codes 81194, 81301, 81455, and 81479. 
 
You asked the Plan to pay for genetic testing. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 
16, 2022, billed with codes 81194, 81301, 81455, and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 26862) provided to the 
enrollee on December 1, 2021. 
 
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 the billed procedure code supports one unit for this date of service. 
 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 26862 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 surgical services 
(procedure code 26862) provided to the enrollee on December 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to lower the $35 copayment for a physical therapy visit on December 9, 
2021. 
 
You asked the Plan to lower the $35 copayment for a physical therapy visit. You say that you are on a limited 
income and can't afford to pay this. The Plan denied your request. The Plan says the copayment has been 
applied 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 $35 
copayment for physical therapy.  
 
You have been asked to pay a $35 copayment for a physical therapy visit. A physical therapy visit falls within 
the Outpatient Rehabilitation Services 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 lower the $35 copayment 
for a physical therapy visit on December 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on January 10, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
reprocessed and paid. 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 office visit (99204) provided on January 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance and ground services (CPT code(s): A0429 and 
A0425) provided on June 25, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim is not payable as billed. 
 
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 ambulance and ground services (CPT 
code A0429 and A0425) provided on June 25, 2021, have been met. The ambulance trip report was not 
included; therefore, the claim cannot be paid. Therefore, we decided that the Plan does not have to pay for 
ambulance and ground services (CPT code(s): A0429 and A0425) provided on June 25, 2021.