Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from September 23, 2021, through 
September 26, 2021. 
 
You asked the Plan to pay for the 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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The provider did not bill as 
required by Medicare coding regulations. CPT code G0378-GZ (19 units) denied per Hospital OPPS OCE edit 
51 as all hours for the entire period of observation must be included on a single line. Therefore, as CPT code 
G0378 was reported September 23, 2021, on two claim lines with 48 units and 19 units; per the guidelines, we 
find the Medicare rule for payment for all charges including procedure codes 97163, 97166, and 99285 for this 
September 23, 2021, through September 26, 2021, claim has not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided from September 23, 2021, through September 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp. 
 
You asked the Plan to pre-approve a ramp. You say that this is medical equipment. The Plan denied your 
request. The Plan says this is not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ramp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on November 23, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON drug testing. You say that this testing was medically necessary and 
should be paid. The Plan denied your request. The Plan says this testing was not emergent and was ordered by 
an OON provider. No authorization for the ordering provider or OON testing was requested. 
 
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 drug testing provided on November 23, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing provided on October 12, 2021, ordered by a 
network provider. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that the documentation does not include screening test results which are 
positive or inconsistent with prescription medications, dosing schedules, or history and expected results. 
 
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. 
 
The enrollee was referred for the drug testing by a contract provider. The file does not show that the plan 
provided notice that the drug testing would not be covered. Under Medicare rules, this means the drug testing is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the definitive drug testing 
provided on October 12, 2021, ordered by a network provider.  
 
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 drug testing (80307, G0480) rendered by the out-of-
network (OON) provider on December 6, 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 drug testing (80307, G0480) rendered by the out-of-network (OON) provider 
on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent testing by nucleic acid provided on 
November 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the testing was provided OON and ordered by an OON provider. This was 
not emergency testing, and no authorization was requested for either the ordering provider's services or the lab 
services. 
 
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 infectious agent testing by nucleic acid 
provided on November 12, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on June 4, 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 the denied codes remain 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 the denied codes is: 
 
CPT 11043: 
 
Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 
sq cm or less 
 
CPT 29581: 
 
Application of multi-layer compression system; leg (below knee), including ankle and foot  
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 not supported by the medical records. Our reviewer found the procedure report does not include 
documentation to support debridement muscle and/or fascia to support CPT 11043. In this case, measurements 
do not support what tissue was debrided, and therefore cannot be verified. In terms of CPT 29581, the provider 
is reporting wound dressing separate from the wound care. This procedure would be inclusive to wound care, 
and not reported separately. In this case, documentation does not support wound care, and therefore the wound 
dressing would not be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0483) 
provided on June 8, 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. 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. CPT code(s): G0483 
and 80307 remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location 
of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen 
was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history 
indicates that the specimen was obtained in an office setting POS 11; therefore, the billed codes cannot be 
verified. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 
80307 and G0483) provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on October 4, 2021. 
 
You asked the Plan to pay for these compression stockings. You say that these compression stockings were 
medically necessary. The Plan denied your request. The Plan says compression stockings coded as A6530 are 
not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  Although this item may be 
appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
A6530 that were issued on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full length hospital bed rails. 
 
You asked the Plan to pre-approve full length hospital bed rails. You say that full length hospital bed rails are 
necessary to keep you from falling. The Plan denied your request. The Plan says full length hospital bed rails 
are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is precautionary and is not covered. Therefore, we decided that the Plan does not have to pre-approve 
full length hospital bed rails.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker with seat for the enrollee. 
 
You asked the Plan to pre-approve an upright walker with seat. You say that this walker is medically necessary 
for the enrollee. The Plan denied your request. The Plan says this specialized walker is not covered.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also say walkers must be obtained from Medicare eligible providers. Although 
upright walkers are durable medical equipment by Medicare's standards, they are not covered because upright 
walker suppliers do not accept Medicare payment structures. Therefore, we decided that the Plan does not have 
to pre-approve an upright walker with seat for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on October 31, 
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 this was billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered inpatient, the 
inpatient POS code would be used regardless of where the face to face service takes place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the outpatient POS code. 
The records show that the enrollee was registered inpatient at this time. Therefore, we decided that the Plan 
does not have to pay for radiology services provided to the enrollee on October 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says a study similar to the one requested has recently been performed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found you have had prior 
hysterectomy, cholecystectomy and appendectomy. You have had recent split renal function test, 
esophagastroduodenoscopy (EGG), and colonoscopy on 2/11/22. Computed tomography (CT) of the abdomen 
and pelvis was done 12/7/21. All of these tests failed to identify a problem responsible for the enrollee's 
symptoms. MRI of the abdomen has not been discussed as medically necessary by any of the consultants in the 
medical records and the medical necessity of the test has not been established. 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) 
rendered by the out-of-network (OON) provider on November 24, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the out-of-network 
(OON) provider on November 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on May 3, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the immunotherapy injection (95115) 
provided on December 1, 2021. 
 
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 service 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 for lab services provided at a 
primary care physicians (PCP) office, specialists office, and a free standing laboratory. Additionally, you 
must pay a $40 copayment for lab services provided at an outpatient hospital. 
 
You have been asked to pay a $14.80 copayment for the lab service provided at an outpatient hospital. This is 
the Plans allowed amount for this service which is less than the applicable copayment. 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 immunotherapy injection (95115) provided on December 1, 
2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing (CPT code G0483) provided on June 28, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that this service is redundant and has been performed by the same and/or 
different provider on the same date of service, June 28, 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan only provided the remittance for the code billed, but there are no other 
documents verifying the provider billed the services twice. Therefore, we decided that the Plan has to pay for 
the drug testing (CPT code G0483) provided on June 28, 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 a facet joint injection in a third level (64495) billed for date 
of service November 25, 2020. 
 
You asked the Plan to pay for a facet joint injection. You say that you have provided records to substantiate the 
service at issue. The Plan denied your request. The Plan says rules for payment have not been met because the 
available records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64495 is "Injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 
procedure)." 
 
 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 a facet joint injection. Our reviewer says that the service at 
issue does not meet criteria for reimbursement. Our reviewer found that only two levels were injected 
according to the procedure note. A third level was not injected. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for a facet joint injection in a third level (64495) billed for date of service November 25, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 24, 2021. 
 
You asked the Plan to pay for the laboratory 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).