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

 
We decided that the Plan does not have to pay for the transplant evaluation services provided from November 
20, 2021, to December 26, 2021. 
 
You asked the Plan to pay for the physician services. You say that your medical condition significantly impacts 
your daily life. You say that the provider advised the liver transplant was medically necessary for you. You 
also say that the services you received were for an emergency related to the liver issue. The Plan denied your 
request. The Plan says transplant evaluation services are not an emergency. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Specifically, transplant evaluation services are not 
considered urgent or emergent. Therefore, we decided that the Plan does not have to pay for the transplant 
evaluation services provided from November 20, 2021, to December 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99199) provided on August 11, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99199 is "Unlisted special service, procedure or report". 
 
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 use of codes 99199 is 
not supported by the records provided. Our reviewer found that the operative report does not indicate what 
procedure this code is being reported for. After careful review of medical record, an unlisted special service, 
procedure or report was not found, and therefore cannot be verified. 
 
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 the services (99199) provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on February 23, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you paid at the time of service and are 
now being told that the copayment went up. 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 $50 
copayment for each covered visit or consultation in an outpatient location with a specialist. Covered services 
include: Consultation, diagnosis, and treatment by a specialist. 
 
 
 
 
 You have been asked to pay a $50 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's 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 office visit on February 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and computed tomography (CT) scan 
(70486) provided on December 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and CT scan. The Plan denied your request. The Plan says the 
services were provided out-of-network and 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 the office visit (99213) and computed tomography 
(CT) scan (70486) provided on December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81295, 81298, 81201, 81317, 
81432, and 81479 provided on January 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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, we have confirmed that codes 
81295 and 81298 are column II codes to column I code 81432 with a modifier indicator of 0. The column II 
code is therefore not payable. 
 
We find that CPT codes 81201, 81317, 81432, and 81479 are not supported in the medical record. Specifically, 
when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be 
considered part of the same panel. A panel constitutes one single procedural service, so one code must be 
submitted for the panel. Review of the file does not support that only one code was submitted for the panel 
provided. 
 
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 laboratory services coded 81295, 81298, 81201, 81317, 81432, and 81479 
provided on January 25, 2022.
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 your accident has led to the need for medically 
necessary rehabilitation of your whole body. The Plan denied your request. The Plan says that you do not have 
medical complexities to warrant physician oversight. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of hip fracture 
and wrist fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 sets of crowns (D2751) of tooth #19 and partial 
maxillary and mandibular dentures (D5225, D5226). 
 
You asked the Plan to pre-approve these services. You say that these services are necessary. The Plan denied 
your request. The Plan says that there is no documentation as to why these services are needed. 
 
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. The Plan covers these services 
when the services are medically necessary and reasonable.  
 
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 these services. Our reviewer says that 
these services are not medically reasonable and necessary. The documentation provided was not sufficient to 
determine if the criteria for coverage for these services have been met. Our physician reviewer found that your 
condition does not meet criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 2 sets of crowns (D2751) of tooth #19 and partial maxillary and mandibular dentures 
(D5225, D5226).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a split-thickness skin graft (15120) provided on February 10, 
2022. 
 
You asked the Plan to pay for a split-thickness skin graft. You say that you have provided medical records to 
support the service at issue. The Plan denied your request. The Plan says rules for payment have not been met 
because the available medical records do not support the service 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 15120 is "Split-thickness autograft, face, scalp, eyelids, 
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body 
area of infants and children (except 15050)." 
 
 
  We find that CPT code 15120 is not supported in the medical record. Specifically, the available medical 
records do not document the size of the graft. Based on this information, we decided that Medicare rules for 
coverage of a split-thickness skin graft have not been met. Therefore, we decided that the Plan does not have to 
pay for a split-thickness skin graft (15120) provided on February 10, 2022.
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 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 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 based on the medical records provided there is no documentation that the enrollee 
requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.  
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 hospital outpatient clinic visit provided on November 2, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that you have a direct, independent 
right to recover funds outside of a contract for any services provided to the Plan's enrollees. 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 
hospital outpatient clinic visit. We found no exception that would require the Plan to pay for the hospital 
outpatient clinic visit. The records provided for review do not show that the hospital outpatient clinic visit was 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic 
visit provided on November 2, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for psychotherapy services provided from 
January 25, 2022, to March 2, 2022. 
 
You asked the Plan to waive the copayments for the psychotherapy services. You say that you are on social 
security and cannot afford the copayments. 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 $25 
copayment for each individual or group therapy visit.  
 
You have been asked to pay a $25 copayment for each of the 4 visits for the psychotherapy services. The total 
for all visits is $100 ($25 copayment x 4 visits = $100). The psychotherapy services fall within the Outpatient 
Mental Health Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for psychotherapy 
services provided from January 25, 2022, to March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid examination and selection 
(92590) provided on January 13, 2021. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable 
benefit for this service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan contract states that you have coverage up to 
$400 every year for a hearing aid, hearing aid evaluation, and fitting. The Plan issued payment to you on  
March 30, 2021 in the amount of $500 for the hearing aid purchased. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aid examination and selection (92590) provided on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient procedure provided on July 12, 
2021. 
 
You asked the Plan to waive the copayment for outpatient procedure. You say that you used to pay $50 
copayment for the procedure so you shouldn't have to pay more now. The Plan denied your request. The Plan 
says the copayment applied 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 $385 
copayment for Medicare covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 
 You have been asked to pay a $385 copayment for outpatient procedure. Outpatient procedures fall within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 outpatient procedure 
provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00635) provided December 18, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia services was not filed until February 11, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for anesthesia services (00635) provided December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 4 standard, multiple power option, sling/solid 
seat/back power wheelchair and accessories (K0884, E2300, E2363, K0108, E1007, E2311, E2620, E2624, 
E0955, E1028, E0956, E2377, E2313). 
 
You asked the Plan to pre-approve a group 4 standard power wheelchair and accessories. You say that the 
requested wheelchair is a special accommodation due to the severity of your disability. The Plan denied your 
request. The Plan says a group 4 power wheelchair has features that are not needed for use in the home and are 
never covered by Medicare or the Plan.  A request for a wheelchair that meets your needs and Medicare rules 
(Group 3 wheelchair) can be reviewed if submitted. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a group 4 standard, multiple power option, sling/solid seat/back power wheelchair and 
accessories (K0884, E2300, E2363, K0108, E1007, E2311, E2620, E2624, E0955, E1028, E0956, E2377, 
E2313).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided from 
September 16, 2021, to September 29, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered. The Plan 
denied your request. The Plan says the provider in this case is not eligible to participate with Medicare. 
 
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. 
 
Review of the file and 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 home visit for hemodialysis (99512) 
provided from September 16, 2021, to September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (R0075, 71046, Q0092) provided August 
16, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code R0075, 71046, & Q0092 is not supported in the medical record. Specifically, the same 
provided billed for both the technical component and professional component of this service. Based on this 
information, we decided that Medicare rules for coverage of the radiology services have not been met.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for radiology services (R0075, 71046, Q0092) 
provided August 16, 2021.