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

 
We decided that the Plan does not have to pre-approve the special supplemental benefit for the chronically ill. 
 
You asked the Plan to pre-approve the special supplemental benefit for the chronically ill. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
SSCBI have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the special supplemental benefit for the chronically ill have not been met. Specifically, we have 
confirmed that the enrollee does not require the need for intensive care management services. Therefore, we 
decided that the Plan does not have to pre-approve the special supplemental benefit for the chronically ill.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hereditary pharmacogenomic testing and 
hereditary genetic cardiac testing provided on April 18, 2022, billed with codes 81225, 81226, 81227, 81230, 
81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 81479, 
81407, 81406, and 81238. 
 
You asked the Plan to pay for the genetic testing. You say that the medical records have been attached to this 
appeal. Please have a look at the attachment and reconsider the charges which were previously denied. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. There is no documentation from the provider documenting the drugs 
being considered for use, and no documentation to how the results will impact treatment. The state where the 
provider performs the service differs from the state where the enrollee resides. The provider is located in 
Florida, while the enrollee resides in North Carolina.  Based on this information, we decided that Medicare 
rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the comprehensive hereditary pharmacogenomic testing and hereditary genetic cardiac testing 
provided on April 18, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 
81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 81479, 81407, 81406, and 81238.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on July 07, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollees network primary care provider (PCP) or plan must give 
the enrollee approval in advance before they can use providers not in the plan's network. This is called giving 
you a "referral." 
 
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 outpatient mental health provided on July 07, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) 
care provided from January 19, 2022, through February 14, 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 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). The enrollees contract with the Plan clearly says that he must pay  
a $0 copay per day, per stay, for days 1-20 and a $150 copay per day, per stay, for days 21-100 for skilled 
nursing facility (SNF) care rendered by an in-network provider. 
 
The enrollee has been asked to pay $900 ($150 copay x 6 days) for the skilled nursing facility care rendered by 
an in-network provider. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the inpatient skilled nursing 
facility (SNF) care provided from January 19, 2022, through February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on June 2, 2022 
and billed under codes A6222 and A6219.  
 
You asked the Plan to pay for codes A6222 and A6219. You say that this claim should be paid. The Plan 
denied your request. The Plan says codes A6222 and A6219 have a status code indicator of 'P' on the CMS 
Physician Relative Value File. These codes are always bundled into payment for other services and no separate 
payment is made by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the codes billed cannot be paid separately based on the billing guidelines. Medicare rules for coverage of 
codes A6222 and A6219 have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided to the enrollee on June 2, 2022, and billed under codes A6222 and A6219.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab codes 82570, and 83986. 
 
You asked the Plan to pay for codes 82570 and 83986. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says The Plan says codes 82570 and 83986 are included in the 
billing of coded 80307 and G0481 which were paid by the Plan. These codes are not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, it has been confirmed that these codes 
are not separately payable. Medicare rules for coverage of this claim have not been met. Therefore, we decided 
that the Plan does not have to pay for lab codes 80307, G0481, 82570, and 83986.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 06, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 lab testing provided on September 06, 2021, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided the Plan does not have to pay for imaging services (70450) provided on July 23, 2022. 
 
You asked the Plan to pay for this claim. You say that this service should be paid by the Plan. The Plan denied 
your request. The Plan says Medicare guidance shows a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 70496 and 70450 This PTP edit has a modifier indicator of 1, which 
indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not 
billed with this PTP code edit on the claim.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when required the appropriate modifier.  
In this case, the claim submitted cannot be paid as billed due to the omission of the required modifier.  
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have 
to pay for imaging services (70450) provided to the enrollee on July 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services on January 25, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you want to appeal the amount being 
charged. 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 $45 
copayment for lab services at outpatient hospital. Covered services include but are not limited to laboratory and 
diagnostic tests billed by the hospital. 
 
You have been asked to pay a $45 copayment for lab services. This item/service falls within the Outpatient 
hospital 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 lab services on 
January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block provided to the enrollee on March 
29, 2022. 
 
You asked the Plan to pay for the block. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of a genicular nerve block in the setting of knee pain 
have not been demonstrated in the peer-reviewed literature. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the role of genicular nerve blocks and of radiofrequency ablation of the genicular nerves is the 
subject of ongoing clinical trials. This is still considered experimental and investigational therapy at this point. 
Therefore, the procedure was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the block have not been met. Therefore, we decided that the Plan does not have 
to pay for a genicular nerve block provided to the enrollee on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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, for 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 May 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on June 3, 2022, by an OON provider. 
 
You asked the Plan to pay for the walker. You say that you purchased the walker and you are asking for your 
80% reimbursement. 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 a walker provided on June 3, 2022, by an OON 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 27, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
include the time spent. This means the documentation does not support that 30-74 minutes was spent on this 
service. Based on this information, we decided that Medicare rules for coverage of the critical care services 
have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 
99291 provided on May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on April 29, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want appeal the amount 
being charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment for each Medicare-covered outpatient hospital facility visit. If you are having 
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or 
outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient 
and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might 
still be considered an outpatient. The provider billed in the amount of $600 and the allowed amount is 
$143.88. This is less than the copayment amount. Therefore, results in the total cost sharing amount of $143.88. 
 
 
 
 The enrollee has been asked to pay a $143.88 copayment, which is less than the copayment for outpatient 
services. This item/service falls within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for outpatient services on April 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient skilled nursing facility (SNF) 
care provided from August 7, 2021, through September 14, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments were applied correctly to 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 $0 
copayment per day, for days 1 to 20 and a $60 copayment per day, for days 21-100 for skilled nursing services.  
 
You have been asked to pay $1,080 ($60 copayment x 18 days) for the inpatient skilled nursing facility care 
provided from August 7, 2021, through August 30, 2021 and September 1, 2021, through September 14, 2021.  
The Plan contract states that you must pay a $0 copayment per day, for days 1 to 20 and a $60 copayment per 
day, for days 21-100 for skilled nursing services. 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 the inpatient skilled nursing facility (SNF) care provided 
from August 7, 2021, through September 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 12, 2022, to 
February 8, 2022. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the provider 
did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that the admission date on the NOA must always 
match the from date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services provided from January 12, 2022, to February 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 20, 2022, to 
February 18, 2022. 
 
You asked the Plan to pay for the home health services. 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 all HHAs must submit a NOA at the beginning 
of the initial 30-day period of care. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted at the beginning 
of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from January 20, 2022, to February 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial for admission to an IRF. 
The Plan denied your request. The Plan says that the 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 that 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. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 3, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the decision to deny the 
claim on the basis of requiring prior authorization or advanced notification. 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 laboratory services provided on August 3, 2022, 
by an OON provider.