Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor CGM and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you were advised by your provider that 
the request was submitted. You also say that you have been pricking your finger for 20 years and you cannot do 
it anymore. The Plan denied your request. The Plan says you do not meet the criteria for a Dexcom G6 CGM or 
supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or have a Medicare-covered continuous subcutaneous insulin infusion (CSII) 
pump. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose 
monitor CGM and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician or allowed practitioner certification for Medicare-
covered home health services under a home health plan of care (patient not present), provided on November 2, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physician or allowed practitioner certification for Medicare-covered home health 
services under a home health plan of care (patient not present). You say that you did not know that the facility 
failed to get pre-authorization for this patient, so we treated this patient anyway. The Plan denied your request. 
The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the 
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 physician or allowed practitioner certification for 
Medicare-covered home health services under a home health plan of care (patient not present), provided on 
November 2, 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 
December 17, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were still under the care of the 
hospital since you went to the ER after your colonoscopy. 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 $90 
copayment for an emergency room visit.  
 
You have been asked to pay a $90 copayment for an ER visit. An 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 December 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110) provided on 
August 13, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
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 service. Our reviewer found the documentation describes 
therapy services performed in the home setting. In this case, a Healthcare Common Procedure Coding System 
(HCPCS) code should be reported. 
 
  
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the therapeutic procedure (CPT code 97110) provided on August 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician or allowed practitioner certification for Medicare-
covered home health services under a home health plan of care (patient not present) provided on December 13, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physician or allowed practitioner certification for Medicare-covered home health 
services under a home health plan of care (patient not present). You say that authorization was not obtained 
prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their parents. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and authorization 
was not obtained prior to the 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 physician or allowed practitioner certification for 
Medicare-covered home health services under a home health plan of care (patient not present) provided on 
December 13, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (CPT code 
77002-26, RT) provided on September 10, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. 
 
CPT code 77002-26, RT and 77002-26, XU, LT exceed the allowable UOS of 1 for the same date of service. 
Per the MAI indicator of 3 77002-26, RT and 77002-26, XU, LT were not billed correctly per the bilateral 
surgery indicator of 0. We find that Medicare rule for payment of this claim has not been met. If the provider 
determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a 
submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not 
have to pay for the fluoroscopic guidance for needle placement (CPT code 77002-26, RT) provided on 
September 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of peritoneal foreign body from peritoneal cavity 
(CPT code 49402) provided on September 11, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 49402 has a status indicator of 1 which does not allow for assistant surgeon payment. Therefore, 
we decided that the Plan does not have to pay for removal of peritoneal foreign body from peritoneal cavity 
(CPT code 49402) provided on September 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies (CPT code 99072) provided on October 
22, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. 
 
Procedure code 99072 has a status indicator code B. Procedure codes with a status indicator of B are always bundled into payment for other services not specified and no separate payment is made per Medicare. 
Therefore, we decided that the Plan does not have to pay for additional supplies (CPT code 99072) provided on 
October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81003, 87481, 87500, 
87640, 87641, 87653, and 87798) provided on November 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 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 laboratory 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 the laboratory services (CPT code(s): 81003, 87481, 87500, 87640, 
87641, 87653, and 87798) provided on November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory service provided on March 
18, 2022. 
 
You asked the Plan to waive the copayment for the laboratory service. You say that you informed the medical 
associates and doctor that you did not want any procedure that would exceed your plans copayment. The Plan 
denied your request. The Plan says you have been charged the correct copayment 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 $10 
copayment for x-rays, laboratory, and other diagnostic tests for each category per service dates.  
 
 
 
 
 You have been asked to pay $8.46, which is less that than the $10 copayment for the laboratory service. The 
laboratory service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the laboratory service provided on March 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 2, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided on November 
19, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
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 drug testing 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 the drug testing (CPT code G0482) provided on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 81455) 
provided on October 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this is medically necessary and used to help 
determine treatment options. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of targeted genomic sequence analysis 
panel (Current Procedural Terminology (CPT) code 81455) provided on October 5, 2021, have been met.  There are no clinical records from the treating physician who ordered the testing to verify the services were 
necessary. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis 
panel (CPT code 81455) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for an office visit. We decided that the Plan does not 
have to waive the deductible for an office visit.  
 
You asked the Plan to waive the cost-sharing for an office visit. You say that annual wellness visits should be 
covered 100%. The Plan says that the cost-sharing applied was correct. 
 Please note that your services were billed as an office visit and not as an annual wellness exam. 
 
We decided that the Plan has to reduce the coinsurance for an office visit.  
 
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 10% 
coinsurance for doctor and other health care provider services.  
 
You have been asked to pay $14.42 for an office visit. Based on the Plan contract, however, you cannot be 
asked to pay more than a 10% coinsurance for an office visit. The allowed amount of the claim is $144.42, 
minus $129.85 towards your deductible, resulting in a coinsurance amount of $1.44 ($144.42 - $129.85 = 
$14.42, $14.42 x 10% = $1.44 coinsurance). Therefore, we decided that the Plan has to reduce the coinsurance 
for an office visit.  
 
We also decided that the Plan does not have to waive the cost-sharing for an office visit. 
 
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 there is a $800 
combined in-network and out-of-network annual deductible for covered medical services. Therefore, we 
decided that the Plan does not have to waive the deductible for an office visit. 
 
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 an office visit provided on January 18, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on January 18, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
31, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the provider only took blood 
pressure and told you that you had cancer. 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 $45 
copayment for each visit with a specialist.  
 
You have been asked to pay a $45 copayment for the office visit. The office visit falls 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 a specialist office visit provided on January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 8 to July 14, 
2021. 
 You asked the Plan to pay for inpatient hospital services. You say that the medical record clearly supports the 
provided diagnosis. The Plan denied your request. The Plan says rules for payment on the basis of DRG 480 
have not been met. 
 
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 diagnosis code, J96.01, defined as "Acute 
respiratory failure with hypoxia". 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 inpatient 
hospital services. Our reviewer says that the available medical records do not support DRG 480 and ICD-10 
code J96.01. Our physician reviewer found that the hospital record does not support reporting a diagnosis of 
acute respiratory failure for the current encounter.  
 
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 inpatient hospital services provided on July 8 to July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home visit services provided on January 31, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Home visit services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 Home visit services provided on January 31, 2022 
by an out-of-network (OON) provider.