Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for apolipoprotein testing provided on March 8, 2022. 
 
You asked the Plan to pay for lab test. You say that the provider should have informed you that this test was 
not covered. The Plan denied your request. The Plan says that the denial of payment for this test is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether this testing was ordered by an in-network or 
out-of-network physician. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this 
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
apolipoprotein testing provided on March 8, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided on May 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 83789 is Mass spectrometry and tandem mass 
spectrometry, not elsewhere specified. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, no documentation was 
provided to detail what the testing at issue included. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (83789) provided on May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code  billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code . You say that this service was medically necessary. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 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 78264 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 
procedure code  have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code  billed for date of service May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L3960) provided July 19, 2021. 
 
You asked the Plan to pay for the orthosis. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed item. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not discuss the need for this equipment. 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 an orthosis (L3960) provided July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92960 billed for date of service April 14, 
2021. 
 
You asked the Plan to pay for procedure code 92960. 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 92960 is bundled into 
payment for code 99291. 
 
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 92960 
is a column II code to column I code 99291. 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 92960 billed for date of service April 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic services (97110) provided on September 10, 
2021. 
 
You asked the Plan to pay for the therapeutic services (97110). 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 as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapeutic services (97110) provided on 
September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment (DME) on 
January 16, 2022. 
 
You asked the Plan to waive the copayment for durable medical equipment (DME). You say that you want to 
appeal the amount being charged. 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 20% 
coinsurance for Medicare-covered durable medical equipment. Covered items include, but are not limited to 
wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use 
in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. We 
cover all medically necessary DME covered by Original Medicare. If our supplier in your area does not carry a 
particular brand or manufacturer, you may ask them if they can special order it for you. The provider billed in 
the amount of $167.93 and the allowed amount is $63.68. $63.68 x 20% = $12.74. Therefore, results in the 
total cost sharing amount of $12.74. You have been asked to pay a 20% coinsurance for durable medical equipment (DME). Durable medical 
equipment (DME) falls within the Durable medical equipment (DME) and related 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 durable medical equipment (DME) on January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 28, 2022, to April 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and the services were 
not referred by a network provider or rendered in an in-network facility. The Plan also says that these services 
were not 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 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 psychotherapy provided on January 28, 2022, to 
April 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on June 13, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you have never had to pay a 
copayment in this office before and you are not going to pay it now. 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 $40 
copayment for Physician/Practitioner services, including doctors office visits. 
 
 
 
 
 
 You have been asked to pay a $40 copayment for specialist office visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 specialist office visit provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional chemotherapeutic infusion (96367) billed for date 
of service March 24, 2022. 
 
You asked the Plan to pay for additional chemotherapeutic infusion. 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 have not 
been met because the available 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 96367 is "Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour 
(List separately in addition to code for primary procedure)." 
 
We find that CPT code 96367 is not supported in the medical record. Specifically, the available documentation 
does not indicate the timespan for chemotherapeutic infusion.  
 
 The billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of 
additional chemotherapeutic infusion have not been met. Therefore, we decided that the Plan does not have to 
pay for additional chemotherapeutic infusion (96367) billed for date of service March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 15, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you were sent to the hospital against 
her will and no legal reasons. 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 $265 
copayment per date of service regardless of the numbers of trips for ground ambulance. Covered ambulance 
services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that 
can provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan.   
 
 
 
 You have been asked to pay a $265 copayment for ambulance. Ambulance 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 ambulance on May 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy on April 29, 2022, to May 
13, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you want to appeal the amount 
being charged. 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 20% 
coinsurance for chemotherapy drugs. These drugs are covered under Part B of Original Medicare. Members of 
our plan receive coverage for these drugs through our plan. Covered drugs include drugs that usually arent 
self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, 
or ambulatory surgical center services. The provider billed in the amount of $11,536.50 and the allowed 
amount is $2,684.55. $2,684.55 x 20% = $536.91. There were 3 services. $536.91 x 3 = $1,610.73. Therefore, 
results in the total cost sharing amount of $1,610.73. 
 
 
 You have been asked to pay a 20% coinsurance for chemotherapy. Chemotherapy falls within the Medicare 
Part B prescription drugs 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 
chemotherapy on April 29, 2022, to May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystourethroscopy and a cytopathology provided on April 
8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a cystourethroscopy and a cytopathology. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this provider is a non-network provider who 
does not work with the Plan, and the member self-directed for care. The Plan also says that the member's 
primary care provider did not refer for services. 
 
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 a cystourethroscopy and a cytopathology provided 
on April 8, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on February 15, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you should not have to pay a facility fee 
because they have been waived in the past. 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 $40 
copayment for each Medicare-covered x-ray. Covered services include but are not limited to X-rays. 
 
You have been asked to pay a $40 copayment for x-rays. X-rays 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 x-
rays on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided April 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The records do not show that the test was ordered by the treating 
physician. Outreach by the plan confirmed that the service was not ordered by the physician noted in the 
records. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided April 9, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81455) provided April 5, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan requested office notes and a lab requisition form for this service. This 
information is included in the provided records. Therefore, we decided that the Plan has to pay for genetic 
testing (81455) provided April 5, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in serious need of prosthetic training. The 
Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and or occupational therapy, there is no documented need for an intensive therapy program. Your 
needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the introduction of a catheter of the dialysis circuit and a 
transluminal balloon angioplasty provided on May 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the introduction of a catheter of the dialysis circuit and a transluminal balloon 
angioplasty. You say that the patient has end stage renal disease and is dependent on dialysis hence the surgeon 
provided services based on the patient's necessity. The Plan denied your request. The Plan says this provider is 
not a network provider with the Plan and the services were not referred by a network provider or rendered in an 
in-network facility. 
 
  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 the introduction of a catheter of the dialysis circuit 
and a transluminal balloon angioplasty provided on May 19, 2022, by an out-of-network (OON) provider.