Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a screening test (92551) provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the screening test. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 a $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $10 copayment for the screening test. Screening tests 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 a screening test (92551) provided on December 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the home visit provided on June 9, 2021, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on December 3, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial nursing facility care. You say that an authorization should be on file for 
the patient's stay at the nursing facility. You also say that your practice has been called in for numerous 
consultations on this patient. The Plan denied your request. The Plan says the services are not authorized 
because this provider is a non-network provider who does not work with the members health plan, and the 
member was referred by a provider who also does not work with the members plan. The Plan also says that the 
member's primary care physician (PCP) did not refer for services. The Plan also says that no medical necessity 
for an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 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 initial nursing facility care provided on December 
3, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on October 18, 2021. 
 You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on October 
18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 88361, 88312, 88305 and 
88104 provided May 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please consider that this service can only be 
performed by your office. This is a proprietary test and may not be available in the Plan's network. The Plan 
denied your request. The Plan says services included in the hospital contract rate. 
 
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 88361-XS, 88312-XS, 88305-XS and 88104-XS is not supported in the 
medical record. Specifically, payment for these services were included in the payment made to the facility. Also the records show that another provider rendered the same services, for the same date of service with the 
place of service 22 for outpatient hospital. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded as 88361, 88312, 88305 and 88104 provided May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a fluorodeoxyglucose injection (A9552) 
provided on October 7, 2021. 
 
You asked the Plan to waive the coinsurance for the fluorodeoxyglucose injection. You say that the services 
should be covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 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 a 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the fluorodeoxyglucose injection (allowed is $511 x 20% = 
$102.2). Fluorodeoxyglucose injections 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 coinsurance for a fluorodeoxyglucose 
injection (A9552) provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis 
rendered on December 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 procedure code 74176 is 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 CPT code. In this case, we have confirmed that code 74176 
is a column II code to column I code 74177. 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 the computed tomography (CT) scan of the abdomen/pelvis 
rendered on December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on July 15, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was appropriate and is supported in the 
medical record. The Plan denied your request. The Plan says this service is not supported 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. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records do not 
note how much time was spent providing this service. Based on this information, we decided that Medicare 
rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay 
for critical care, first hour (99291) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
rendered on November 4, 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 are not covered. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. 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 additional 
supplies, materials, and clinical staff time rendered on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the venipuncture and travel allowance rendered on July 27, 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
We looked at the file and Medicare rules. Billed procedure codes G0471 (collection of venous blood by 
venipuncture or urine sample by catheterization from an individual in a skilled nursing facility or by a 
laboratory on behalf of a home health agency) and P9603 (travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled) have a status indicator of X and are excluded from Medicare. Therefore, we 
decided that the Plan does not have to pay for the venipuncture and travel allowance rendered on July 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the maximum-out of pocket for the inpatient hospital stay 
provided from September 23, 2021 to September 28, 2021. 
 
You asked the Plan to waive the maximum-out of pocket the inpatient hospital stay. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 copayment per day for days 1-5 of which applies to Inpatient 
hospital care.  
 
 
  The item or service you asked the Plan to waive the maximum-out of pocket falls within the benefit category 
Inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$300 copayment per day for days 1-5 of which applies to Inpatient hospital care. This cost sharing is a 
contractual obligation that had not been met at the time the inpatient hospital stay was received on September 
23, 2021 to September 28, 2021. Therefore, we decided that the Plan does not have to waive the maximum-out 
of pocket for the inpatient hospital stay provided from September 23, 2021 to September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99072, 36416) provided December 8, 
2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes are not eligible for 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. 
 
We find that CPT codes 99072 & 36416 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 99072 & 36416 are not separately payable. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99072, 36416) provided December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing provided to the enrollee on 
July 19, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no clinical documentation of the stage of cancer. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the reviewed documentation indicates that the pathology report of pancreatic adenocarcinoma without 
staging and test report for 0037U. There is no clinical documentation of the enrollee's stage of cancer - 
initial/advanced/recurrent and treatment plan and no documentation provided indicating that the test result will 
influence the enrollee's medical management. The review has determined that the services at issue in this case 
are not medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne CDx testing provided to the enrollee on July 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0300). 
 
You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says the requested home health services do not 
meet criteria. 
 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 service is not medically necessary. Our physician reviewer found the enrollee does not require 
additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the 
enrollees condition, perform a maintenance program to maintain the enrollees condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. 
 
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 (G0300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on December 
20, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy. You say that the claim was denied due to no 
authorization, but you have authorization for 12 visits. The Plan denied your request. The Plan says CPT codes 
97530, 97112, G0283 have been approved and CPT code 97010 remains denied as bundled services are 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. 
 
 We find that CPT code (97010) has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code (97010) is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the hot or cold packs therapy (97010) provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99204, 99214) provided on September 
28, 2021 to December 2, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
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 physician services (99204, 99214) provided on September 28, 2021 to 
December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on June 24, 2021. 
 
  You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the documentation provided supports the level of service billed and the claim should be reprocessed 
appropriately. The Plan denied your request. The Plan says procedure codes procedure codes 99285 and 12005 
have been overturned. The Plan also says CPT code 99053 remains denied as bundled services are 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. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on June 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing with medical records. The 
Plan denied your request. The Plan says the denial of authorization for home health care is correct. 
 
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 physical therapy. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health. Our physician reviewer 
found the documentation does not support that the enrollee requires additional skilled rehabilitation services to 
provide medically necessary treatment, and/or services in order to improve the enrollee's condition or perform a 
maintenance program. The enrollee has been medically stable without any recent exacerbations 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you do not need a primary care physician referral 
based on your contract. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan, and they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. The Plan also says that this was denied because referral was not authorized by primary 
care physician (PCP). 
 
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 December 7, 2021, by 
an out-of-network (OON) provider.