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

 
We decided that the Plan does not have to pay for an office visit provided on June 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 June 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 26, 2022, to March 29, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says the DRG and secondary diagnosis code is 
not supported. 
 
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 193. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case there was no clinical or laboratory evidence of sepsis. The review has determined that the 
record support the plan's adjusted DRG 195 not the original DRG 193. The records do not support that 
secondary diagnosis code J96.01 was appropriate in this case. 
  
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 inpatient hospital services provided to the enrollee from March 26, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 9, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on July 6, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the chronic care management services. You say that the NPI doesn't require a 
referral or authorization for this service. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chronic care management services provided on 
July 6, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 15, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized by the Plan before the 
services are provided. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on April 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport services provided on May 29, 2022. 
 
You asked the Plan to pay for ambulance transport services. The Plan denied your request. The Plan says the 
services you received were from an out-of-network provider and needed a prior authorization. The services 
were not authorized and are not payable. 
 
The Plan contract covers ambulance services. The Plan says that prior authorization is only required for non-
emergent ambulance transport. 
 
We looked at the file and the Plans rules. The file shows that the Plan required prior authorization for non-
emergent ambulance transport. Therefore, we decided that the Plan does not have to pay for ambulance 
transport services provided on May 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (codes 81238, 81286, 81439, and 81442) 
provided on December 13, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing does not meet 
the criteria for coverage. 
 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 the testing have been met. Specifically, 
there are no medical records, results report, or physicians order. Therefore, we decided that the Plan does not 
have to pay for the genetic testing (codes 81238, 81286, 81439, and 81442) provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for biopsy provided on May 20, 2022. 
 
You asked the Plan to waive the copayment for biopsy. You say that you had the procedure performed in a 
doctors office not in a hospital as outpatient. 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 $200 
copayment for surgical services in an outpatient hospital setting. 
 
You have been asked to pay a $200 copayment for biopsy. This item/service falls within the surgical services in 
an outpatient hospital setting benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for biopsy 
provided on May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 a portable oxygen concentrator Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found that you have a home stationary concentrator and portable tanks that weigh approximately 3 
pounds, with an oxygen conserving device. There is no indication or documentation that the portable tanks do 
not meet your needs, other than for convenience. There are no medical records showing that oxygen saturation 
can be maintained at greater than 91 percent on an oxygen conserving device and 1 to 4 Lpm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. 
Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 7, 2020. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 laboratory services provided on December 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the mammography (77065), extracorporeal 
shock wave therapy (G0279), and ultrasound (76642), provided on June 8, 2022. 
 
You asked the Plan to waive the deductible for outpatient radiology service. You say that you should not have 
any cost share for these services. 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. Your 
contract with the Plan says that there is a $450 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $450 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
outpatient radiology service was received on June 8, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for the mammography (77065), extracorporeal shock wave therapy (G0279), and 
ultrasound (76642), provided on June 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography, of the thorax, 
diagnostic; without contrast material (71250) provided on June 22, 2022. 
 
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 a $150 
copayment per day, per provider, for Medicare covered diagnostic radiologic services.   
 
You have been asked to pay $106.05 for the diagnostic radiology service provided. This is the Plans allowed 
amount for this service, which is less than the applicable copayment. 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 computed tomography, of the 
thorax, diagnostic; without contrast material (71250) provided on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97026) provided on December 17, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider type. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 
97811) and the infrared therapy (97026) provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97026) provided on December 3, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider type. 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.  
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services provided in this case were 
not rendered under the supervision of a physician, physicians assistant, nurse practitioner or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 
97811) and the infrared therapy (97026) provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810) and the unlisted special 
service, procedure or report (99199) provided on April 16, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services rendered are not payable as the 
provider is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the case file and the Medicare records indicates that the provider at issue is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment 
(97810) and the unlisted special service, procedure or report (99199) provided on April 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammography (77065) provided on 
April 6, 2021. 
 
You asked the Plan to waive the copayment for the mammography. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $50 copayment for the mammography. This item/service 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 copayment for a mammography (77065) provided on April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76380 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 76380. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76380 is bundled into payment for code 78803. 
 
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 76380 
is a column II code to column I code 78803. 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 76380 billed for date of service June 7, 2022.