Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 16, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that the patient was in an assisted living 
facility and you rely on the facility staff to get authorization. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
 
 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 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. Therefore, we 
decided that the Plan does not have to pay for medical services provided on November 16, 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 medical services provided on December 9, 2020. 
 
You asked the Plan to pay for the medical services. You say that the patient only provided his Veteran's Affairs 
insurance information, so the provider shouldn't be punished for not filing timely. The Plan denied your 
request. The Plan says you did not file your claim 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 medical services was not filed until December 13, 2021. 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 medical services provided on December 9, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional imaging services provided to the enrollee om October 22, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the charge appears to be a duplicate. 
 
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 71405 is "Radiologic examination, chest; single view." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found a review of the records showed two 
separate one view chest x-rays done on 10/22/21. The second exam followed a chest tube placement. The 
second exam is not a duplicate charge and should be paid. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
additional imaging services provided to the enrollee om October 22, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on October 20, 2020, by an 
OON provider. 
 
You asked the Plan to pay for the physician services. You say that you assumed the authorization had been 
obtained before you rendered the services. 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 physician services provided on October 20, 
2020, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for procedure code 95941. You say that you billed these services correctly. The Plan 
denied your request. The Plan says you billed with an invalid procedure code. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that code 95941 should not be used for Medicare 
purposes.  Because this is a Medicare Health Plan, providers must follow Medicare billing rules.  Medicare 
uses a different code for intraoperative monitoring services. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95941 billed for date of service November 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant to surgery services (23473-AS-LT) provided on 
June 21, 2021. 
 
You asked the Plan to pay for code 23473-AS-LT. 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 Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The revision surgical procedure in question (code 23473-AS-LT) was 
provided within the 90-day global period for the surgical procedure (code 23472-AS-LT) that was provided on 
April 12, 2021. This means that payment for code 23473-AS-LT was included in the payment for code 23472-
AS-LT. Code 23473-AS-LT was not billed with the appropriate modifier indicating that the service was 
unrelated and rendered during the postoperative period of the global procedure. Therefore, we decided that the 
Plan does not have to pay for the assistant to surgery services (23473-AS-LT) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine you received on October 19, 2021. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you think that the Plan should reimburse you 
for this vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your medical 
benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed 
to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the 
Shingles vaccine you received on October 19, 2021.  
 
Benefits for the Shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on December 
29, 2021, and January 5, 2022. 
 
 
You asked the Plan to waive the copayment for the specialist services. 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 $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 You have been asked to pay a $90 copayment for two specialist service visits ($45 x 2 = $90). 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 services provided on December 29, 2021, and January 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says large panel drug tests are rarely needed in an outpatient setting to help guide care.  
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provider must provide a specific reason for doing a definitive drug test. In this record, there is no 
concern noted about potential misuse/abuse of medications, no documentation of the enrollee's risk assessment 
score or information as to why a large panel drug test is needed to help guide care. The review has determined 
that the enrollee does not meet the criteria for this testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on November 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), pelvic ultrasounds (76856, 76857), 
and the ultrasound exam of the abdominal back wall (76770) rendered by the out-of-network (OON) provider 
on May 20, 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 were rendered by an out of 
network provider, without prior authorization. 
 
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 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 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 the office visit (99204), pelvic ultrasounds (76856, 76857), and the ultrasound 
exam of the abdominal back wall (76770) rendered by the out-of-network (OON) provider on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology visit provided on October 6, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON dermatology visit. You say that a referral was not obtained within the 
required time frame, but these services were necessary. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
 
 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 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. Therefore, we 
decided that the Plan does not have to pay for the dermatology visit provided on October 6, 2021, by an out-of-
network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 29, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that a home assessment found high blood 
pressure, but the ER said it was fine. You say that you should not have to pay because it was not your error. 
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 $110 
copayment for each emergency room visit.  
 
 
 The record shows that you were evaluated and treated at the ER. Therefore, you have been asked to pay a $110 
copayment for the ER visit. The ER visit falls within the Emergency 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 copayment for an emergency room (ER) visit provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laryngeal study (92520) provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the laryngeal study. 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 $40 
copayment for Outpatient Rehabilitation Services.  
 
 
  You have been asked to pay a $40 copayment for a laryngeal study. Laryngeal studies fall within the Outpatient 
Rehabilitation 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 a laryngeal 
study (92520) provided on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for your inpatient hospital stay from August 3, 
2021, to August 4, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not even 
there for 24 hours. 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 $300 
copayment each time you are admitted to an acute care hospital.  
 
 
  You have been asked to pay a $300 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital 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 copayment for 
your inpatient hospital stay from August 3, 2021, to August 4, 2021.  
 
Please note that this letter is only regarding dates of service August 3 to August 4, 2021. Please contact the 
Plan regarding dates of service June 24 to June 25, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for the rest 
of the imaging services.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the 
enrollee's condition did not meet the Medicare rules for approval of multiple x-ray services performed as part 
of a mobile dysphagia consultation. We decided that the Plan has to pay for the scout chest x-ray and delayed imaging (CPT 74220).  
 
The Plan follows 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 for CPT 74220. Our reviewer says that this code is 
reasonable and necessary for the modified barium swallow. Our physician reviewer found video analysis of 
swallowing in this clinical scenario is indicated to evaluate for possible aspiration. CPT 74220 - which includes 
a scout chest x-ray and delayed imaging - is indicated in this case. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
the scout chest x-ray and delayed imaging (CPT 74220).  
 
We also decided that the Plan does not have to pay for the rest of the imaging services. 
 
The Plan follows 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 for the rest of the services. Our reviewer says that the 
remainder of the billed x-ray studies are unnecessary in this case. 
 
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 rest of the imaging services have not been met. Therefore, we decided that 
the Plan does not have to pay for the rest of the imaging services. 
 
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 the laboratory services rendered on June 22, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
 
 
 
 We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services at issue in this case were not supported by the 
medical records. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was insufficient clinical evidence to validate a stage 3 sacral decubitus ulcer.  
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 inpatient hospital services provided to the enrollee 
on March 28, 2021. 
. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
enrollee has type 1 diabetes and was admitted and treated in the hospital for an infected foot wound which 
required debridement and antibiotics. A sacral wound with "large ulcer on posterior ankle, round, 
approximately 4 to 5 cm in diameter, significant amount of slough, tender to palpation, erythema surrounding 
the wound, no odor noted." was documented. A diagnosis of L89.153, stage III pressure ulcer, was not 
appropriate in this case based on the provided documentation which didn't clearly describe the wound with full-
thickness tissue loss.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the services at issue in this case were not supported by the medical records.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second pair of diabetic shoes and socks purchased on 
September 2, 2021. 
 
You asked the Plan to pay for diabetic shoes and socks. You say that you would like reconsideration because 
you paid out of pocket for the shoes. The Plan denied your request. The Plan says you have exhausted this 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan covers one pair of diabetic shoes per 
calendar year. 
 
 
 
 
 
 
 
 We looked at your request, the file and Medicare rules. Based on this information we have determined that 
criteria for coverage of the additional diabetic shoes have not been met. Specifically, the record indicates that 
the Plan paid for one pair of diabetic shoes. This benefit as been exhausted. Therefore, we decided that the Plan 
does not have to pay for the second pair of diabetic shoes and socks purchased on September 2, 2021.