Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for inpatient hospital services provided from April 14, 2022, 
to April 15, 2022. 
 
You asked the Plan to hold you harmless for inpatient care. You say that these services were medically 
necessary and emergent, and should be paid by the Plan. The Plan denied your request. The Plan says that these 
services are denied due to a billing error. 
 
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 follows these rules. 
 
You were provided inpatient care by a contract provider. The file does not show that the Plan provided notice 
that inpatient care would not be covered. Under Medicare rules, this means inpatient care is considered 
approved by the Plan. In addition, the record shows that these services were denied due to a billing error on the 
submitted claim. Billing issues are disputes between the Plan and the provider, and the enrollee is not 
responsible for billing issues. Therefore, we decided that the Plan has to hold you harmless for inpatient 
hospital services provided from April 14, 2022, to April 15, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic life support, emergency ambulance transport coded 
A0429 provided on October 13, 2021. 
 
You asked the Plan to pay for the basic life support, emergency ambulance transport. You say that you disagree 
with the Plan. 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, the CPT Code Manual definition of code A0429 is ambulance service, basic life support, 
emergency transport (bls-emergency). 
 
 
 We find that CPT code A0429 is not supported in the medical record. Specifically, the documentation provided 
indicates the response to the scene was classified as non-emergent. In addition, the documentation indicates the 
destination modifiers on the claim (HE) were accurate, and the transportation was not provided to a facility 
where appropriate treatment of an emergent health condition could reasonably be provided. This means the 
claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
basic life support, emergency ambulance transport have not been met. Therefore, we decided that the Plan does 
not have to pay for the basic life support, emergency ambulance transport coded A0429 provided on October 
13, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) 
provided July 18, 2021. 
 
You asked the Plan to waive the copayment for the emergency visit. You say that because of a non-stop 
intensive bleeding from the inside of the bottom lip, you were forced to go to the hospital emergency. There 
you were visited with and released on the same day. The Plan denied your request. The Plan says the claim was 
processed with the correct cost share applied per the Evidence of Coverage. 
 
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 $120 
copayment for in network emergency services.  
 
You have been asked to pay $120 copayment for the emergency visit. The emergency 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 the emergency 
department visit (99282) provided July 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation and mileage services provided 
on April 12, 2022. 
 
You asked the Plan to pay for the ambulance transportation and mileage services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the diagnosis code billed is 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. 
 
We find that CPT codes A0427 and A0425 are not supported in the medical record. Specifically, these codes 
were billed with a diagnosis of "localized swelling, mass and lump, unspecified lower limb" and the 
documentation supports swelling of the lower extremities. This means that the diagnosis code billed for these 
services is not supported by the documentation and therefore, the claim cannot be paid as billed. Based on this 
information, we decided that Medicare rules for coverage of the ambulance transportation and mileage services 
have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
and mileage services provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 2, 2022 billed with 
codes 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. While this was the only code billed on this claim, the documentation shows that other codes were 
submitted on a different claim form, but the testing was performed at the same time on the same specimen.  
 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 genetic testing provided on February 
2, 2022 billed with codes 81479.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomographic angiography (CTA) scan (75635) 
provided on November 26, 2021. 
 
You asked the Plan to pay for a CTA scan. You say that you have provided medical records to support the 
service at issue. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 18, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for a CTA scan have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomographic angiography (CTA) scan (75635) 
provided on November 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is the correct code to be billed. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 the lab services provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections do not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found in this case, there is no 
documentation that the enrollee participated in a physical therapy program. The review has determined that the 
requested facet joint injections do not meet the Medicare LCD coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the percutaneous transcatheter placement of 
drug eluting intracoronary stent, with coronary angioplasty (C9600) and non-covered item or service (A9270) 
provided May 2, 2022. 
 
You asked the Plan to waive the copayment for the surgical procedure. You say that you are appealing the 
balance of this surgery on May 2, 2022, for the self-administered drugs and the balance of this bill. No drugs 
were given that was not needed for this surgery. The Plan denied your request. The Plan says the claim was 
processed with the correct cost share applied per the Evidence of Coverage. 
 
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 4% 
coinsurance for each outpatient hospital visit.   
You have been asked to pay $461.01 ($83.24 for self-administered drugs coded as A9270 and $377.01 
coinsurance for the surgical procedure coded as C9600). We find that procedure code A9270 was also billed 
with the GY modifier. The GY modifier is used to notify Medicare that you know that this service is excluded, 
is statutorily non-covered or is not a Medicare benefit. The surgical procedure falls within the Outpatient 
surgery, including services provided at hospital 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 the percutaneous transcatheter placement of drug eluting 
intracoronary stent, with coronary angioplasty (C9600) and non-covered item or service (A9270) provided May 
2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11102 billed for date of service February 23, 
2022. 
  You asked the Plan to pay for procedure code 11102. You say that the initial specimen was sent for biopsy and 
microscopic examination for a definitive diagnosis. You say that you are disputing the denial. The Plan denied 
your request. The Plan says payment for code 11102 is bundled into payment for code 17262. 
 
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 11102 
is a column II code to column I code 17262. 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 11102 billed for date of service February 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 15, 2022, billed 
with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335 
and 81405. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were billed appropriately 
and are substantiated in the medical record. The Plan denied your request. The Plan says these services were 
not billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. 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 genetic testing provided on 
February 15, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 
81291, 81306, 81328, 81335 and 81405.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 19, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were never told you would need a referral to 
continue to see the same doctors. You say it was reasonable to believe that your follow-up care and subsequent 
surgery at the same hospital that provided her original care. 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 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 provided on November 19, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves 
(E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the Health Plan does not have a network deficiency. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0652) and sleeves (E0667) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect Testing (0012M) provided on February 2, 
2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this testing was medically necessary. 
 The Plan denied your request. The Plan says this testing is not covered by Medicare as the clinical relevance of 
this service is unproven at this time. 
 
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 CxBladder testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the CxBladder panel remains unproven in medical literature. The molecular/genomic testing 
mentioned in the National Comprehensive Cancer Network (NCCN) guidelines for bladder cancer shared no 
commonality with the CxBladder test. In this case, the items/services at issue in this case were 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 CxBladder testing have not been met. Therefore, we decided that the Plan does 
not have to pay for CxBladder Detect Testing (0012M) provided on February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an EKG monitoring system provided on 
May 1, 2022. 
 
You asked the Plan to waive the deductible for an EKG system. You say that you were unaware of this charge, 
and therefore feel you should not need to pay it. The Plan denied your request. The Plan says the deductible 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $680 deductible which applies to durable medical equipment (DME).  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment (DME). The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $680 deductible which applies to durable medical equipment (DME). You have been asked to pay 
$672.32. This cost sharing is a contractual obligation that had not been met at the time an EKG system was 
received on May 1, 2022. Therefore, we decided that the Plan does not have to waive the deductible for an 
Electrocardiographic (EKG or ECG) Monitoring system provided on May 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology (81479) provided on March 
10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 unlisted molecular pathology (81479) provided 
on March 10, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary computed tomography angiogram (CCTA) 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the risk/benefit ratio favors non-invasive work-up 
rather than proceeding directly with coronary angiography. The Plan denied your request. The Plan says the 
notes do not show any heart disease symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 the services. Our reviewer says that the 
requested angiogram is not medically reasonable or necessary. Our physician reviewer found that at issue is the 
medical appropriateness and necessity of coronary CTA in the clinical evaluation of this patient. The patient is 
asymptomatic and low risk. Clinical guidelines for the use of coronary CTA have not been met based on review 
of the submitted clinical documentation. As a result, at this time coronary CTA would not be considered 
medically reasonable and necessary in this patient's clinical management. 
 
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 pre-approve a coronary computed tomography angiogram (CCTA) for the enrollee.