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

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on April 7, 2022. 
 
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 is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test.  
 
The denied test is not a covered benefit at this time. 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 the 
CxBladder test provided to the enrollee on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on April 5, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 code 81455 is not supported in the medical record. Specifically, the date of service billed 
(April 5, 2022) does not match the date the specimen was collected per the records (March 21, 2022). Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided on April 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93307). 
 
You asked the Plan to pre-approve a transthoracic echocardiogram. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Echocardiography is indicated in the evaluation of 
derangements of valvular, myocardial and pericardial structure and function.  
 
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 a transthoracic echocardiogram. Our 
reviewer says that this test is not medically necessary. Our physician reviewer found there is an absence of any 
cardiovascular symptoms according to the submitted records. The enrollee has a diagnosis of hypertension 
only. Clinical guidelines do not support carrying out a transthoracic echocardiogram in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transthoracic echocardiogram have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiogram (93307).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99235 billed for date of service August 20, 2021. 
 
You asked the Plan to pay for code 99235. You say that you have voided the other evaluation and management 
service (code 99217), so code 99235 should be paid. The Plan denied your request. The Plan says you have 
already billed for an evaluation and management service on this date of service, and only one of these is 
permitted per day. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital evaluation and management services 
may be reported only once per day by the same physician or physicians in the same specialty in the same group 
practice. You billed both codes 99235 and 99217 on the same date of service, exceeding the number of 
evaluation and management services permitted per day.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99235 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99235 billed for date of service August 20, 2021.  
 
Your complaint about the voiding of code 99217 is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. We have no evidence that the Plan has received or the Plan has processed this voided code, so you must request any additional information about that from the 
Plan directly. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this service is medically necessary. The Plan denied 
your request. The Plan says IRF 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 the complexity of the patient's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
needs can be met in a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit, and an inpatient 
stay provided from December 10, 2021, to December 22, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit and an inpatient stay. You say that 
you almost died while at this facility and did not get better. You are very dissatisfied with the service here. The 
Plan denied your request. The Plan says you were charged this cost sharing 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 $90 
copayment for emergency room and $250 copayment per day for days 1-7 for an inpatient stay.  
 
You have been asked to pay an $1840 copayment for an emergency room visit and an inpatient stay ($90 ER + 
$1750 for 7 days = $1840 total). An emergency room visit, and an inpatient stay falls within the Emergency 
Care and Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an emergency room visit, and an inpatient stay 
provided from December 10, 2021, to December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from June 17, 
2021, to June 19, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were told by the facility that 
there was a covid fund, and that you would not owe a copayment. The Plan denied your request. The Plan says 
you were charged this cost sharing 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 $250 
copayment each day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay a $250 copayment each day for days 1 to 5 for an inpatient stay. An inpatient stay 
falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an inpatient stay provided from June 17, 2021, to June 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing (80307, G0483) provided on 
February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 laboratory drug testing (80307, G0483) provided 
on February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 16 units of procedure code 88341 billed for date of service 
December 16, 2021. 
 
You asked the Plan to pay for procedure code 88341. You say that you believe that at least 13 units of this code 
should be billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88341 is 13. You billed 16 units of this code, exceeding the MUE. You 
indicated that at least 13 units of this code should be covered based on the MUE value.  While 13 units may be 
coverable, your claim still lists 16 units of this code.  You would need to rebill listing only 13 units of this code (regardless of modifiers added), in order for the Plan to process this code for payment. Based on this 
information, we decided that Medicare rules for coverage of procedure code 88341 have not been met. 
Therefore, we decided that the Plan does not have to pay for 16 units of procedure code 88341 billed for date of 
service December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies provided on 
July 9, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that you must ensure that the patient had adequate 
supplies.  You also don't believe that the Plan should be enforcing clinical coverage rules for CGMs during the 
COVID-19 public health emergency. The Plan denied your request. The Plan says this patient is not on insulin, 
so CGMs and related supplies are not covered.  
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. Based on this information, we decided that Medicare rules for coverage of 
the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous 
glucose monitor (CGM) supplies provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on June 10, 2022. 
 
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 chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on June 8, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for oxygen equipment. You say that you were not told that you would have to buy 
this equipment in-network. The Plan denied your request. The Plan says the denial of payment for this item is 
correct, because this provider is out-of-network with the Plan and approval was not 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 oxygen equipment provided on June 8, 2022 by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on August 
24, 2021. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you believe that the Plan 
should reimburse you for this service. The Plan denied your request. The Plan says non-transport ambulance 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services you received on 
August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
April 30, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that the claim was billed with the 
appropriate AA modifier, which is the correct modifier per CMS guidelines. You say that the claim should be 
reprocessed to pay. The Plan denied your request. The Plan says procedure codes 99100 and 99140 are 
considered bundled and not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
April 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital clinic visit provided on May 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON hospital clinic visit. You say that these services were medically 
necessary and provided in good faith. The Plan denied your request. The Plan says unauthorized, non-plan care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the hospital clinic visit provided on May 31, 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 copayments for a needle biopsy and a colonoscopy with 
endoscopy performed from April 26, 2022, to May 11, 2022. 
 
You asked the Plan to waive the copayments for the biopsy and colonoscopy with endoscopy. You say that you 
were informed there were no copayments and you cannot afford them. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 $200 
copayment per date of service for surgery or services at an ambulatory surgical center and a $350 copayment at 
an outpatient hospital.  
 
You have been asked to pay a $350 copayment for the biopsy and a $200 copayment for the colonoscopy with 
endoscopy, for a total of $550. The biopsy and colonoscopy with endoscopy fall within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient 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 copayments for a needle biopsy and a colonoscopy with 
endoscopy performed from April 26, 2022, to May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (0037U) provided on April 4, 
2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is missing required 
information as required by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that tests approved through the MolDX program must 
be billed with the unique test identifier. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, tests approved through the MolDX program must 
be billed with the unique test identifier, and this claim does not include that identifier. Therefore, we decided 
that the Plan does not have to pay for the genetic testing services (0037U) provided on April 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided from February 8, 2022, to 
March 26, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that these claims were denied in error because 
the patient's diagnosis codes are correct as reported by the patient's doctor. The Plan denied your request. The 
Plan says you billed with an inappropriate primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill diagnoses using proper 
sequencing.  Codes listed in the ICD-10 code book with a "code first" note means that sequencing rules apply.  
This means that the patient's underlying etiology must be sequenced first, and the diagnosis code representing 
the manifestation of dementia, should be coded second.  In this case, you billed diagnosis F01.50 (vascular 
dementia without behavioral disturbance) as the primary diagnosis code.  In the ICD-10 manual, diagnosis 
F01.50 is listed as a "code first" diagnosis.  This means that the patient's underlying etiology must be 
sequenced first as the primary diagnosis and code F01.50 should be secondary.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided from February 8, 2022, to March 26, 2022.