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

 
We decided that the Plan does not have to pay for procedure codes 81225, 81226, 81227, 81230, and 81231 
billed for date of service November 9, 2021. 
 You asked the Plan to pay for procedure codes 81225, 81226, 81227, 81230, and 81231. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 81225, 81226, 
81227, 81230, and 81231 is bundled into payment for code 0078U. 
 
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 codes 
81225, 81226, 81227, 81230, and 81231 are column II codes to column I code 0078U. 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 codes 81225, 81226, 
81227, 81230, and 81231 billed for date of service November 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on April 6, 2022. 
 
You asked the Plan to pay for the ER visit. You say that the enrollee was seen by the ER physician for a 
medically necessary procedure. You say that the chart is coded correctly, and the claim should be reprocessed 
to pay this procedure code. The Plan denied your request. The Plan says the ER visit was denied because it did 
not include the appropriate primary diagnosis. 
 
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 99284 is not supported in the medical record. Specifically, the record shows that this 
claim was billed with a primary diagnosis of J70.5. Per the ICD-10, this diagnosis code has a code first note, 
meaning that the underlying condition should be sequenced first. Based on this information, we decided that 
Medicare rules for coverage of the ER visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the ER visit provided on April 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for office visit on May 05, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says that the cost sharing you are being charged is correct. 
 
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 did not send the correct Evidence of Coverage (EOC) that corresponds 
to the date of service. Therefore, we decided that the Plan has to waive the copayment for office visit on May 
05, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 21, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on 
March 21, 2022 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 9284 provided on 
April 24, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
 
 
 
 
 We find that CPT code 99284 is not supported in the medical record. Specifically, this service is included in 
surgery procedure 28470 (closed treatment of metatarsal fracture). This surgery code 28470 has a global 
surgery period of 90 days. This service was billed within 90 days of the surgery code. This means this service 
is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
emergency department visit coded 9284 provided on April 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multianalyte assays with algorithmic analyses (81599) 
provided on March 23, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that non-payment based on a denial for failure to 
obtain prior authorization for this service is inappropriate for a sole source test of this nature. 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 multianalyte assays with algorithmic analyses 
(81599) provided on March 23, 2022 by an out-of-network (OON) provider.
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 the enrollee needs IRF care. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status. The enrollee can receive further services at 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen system purchased on April 23, 2022. 
 
You asked the Plan to pay for the purchased portable oxygen system. You say that this item had to be 
purchased prior to hospital discharge. The Plan denied your request. The Plan says purchased oxygen 
equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. The portable oxygen equipment in dispute 
was purchased, so it is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the purchased portable oxygen system have not been met. Therefore, we decided that the Plan does 
not have to pay for the portable oxygen system purchased on April 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found based on the low complexity and stability of this enrollee requiring only transfusion and outpatient gynecology consultation, it was not expected that the enrollee would require 
inpatient services that would cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided on January 12, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the hearing aids are not payable as they were 
purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were purchased from an 
out-of-network provider. The Plan contract says that hearing aids ordered from providers other the Plans select 
hearing aid provider are not covered. Therefore, we decided that the Plan does not have to pay for the hearing 
aids (V5298) provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided April 19, 2022. 
 
You asked the Plan to pay for the orthosis. You say that you have attached the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says the services are not supported in the 
medical records received.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case there is no documentation of the specific medical necessity for the requested item. 
The review has determined that the medical records provided did not meet the requirements listed in the LCD 
for Medicare coverage. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DermTech melanoma test (0089U) and TERT promoter 
analysis (81345) provided April 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this denial, 
re-adjudication of the claim for payment so the enrollee will not be punished with a medical bill for seeking 
higher quality and more cost-efficient care in assessing melanoma. The Plan denied your request. The Plan says 
the request for DermTech Melanoma Test does not meet Medicare rules because the provided medical records 
do not indicate whether the lesion meets the size or ABCDE criteria for this test. A review of the literature and 
clinical practice guidelines does not currently support the clinical utility of TERT genetic testing in cutaneous 
lesions that have not been diagnosed as melanoma by first line pathologic or histologic evaluation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
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. Therefore, we decided that the Plan does not have to pay 
for the DermTech melanoma test (0089U) and TERT promoter analysis (81345) provided April 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0426) 
provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $125 copayment for ambulance transportation services. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance transportation services (A0426) provided on December 
16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the breasts. 
 
You asked the Plan to pre-approve an MRI of the breasts. You say that the MRI is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for an MRI breast cancer screening, 
this test is not medically necessary. 
 
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 an MRI of the breasts. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there are no mammogram 
reports which delineate the amount of dense breast tissue which could limit mammography. The enrollee is 
refusing a mammography which is the recommended procedure for screening. The enrollee has had a negative 
bilateral automated ultrasound. An absent mammogram report showing extremely dense tissue which would 
limit the efficacy of mammography. The medical necessity of a breast MRI has not been established in the 
records provided especially given the negative genetic testing noted in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the breasts have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the breasts.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan (93880) provided on April 7, 
2022. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that the services should be covered as 
you disagree with the denial. 
 The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Outpatient diagnostic tests and therapeutic services and supplies, specifically diagnostic tests 
performed by a specialty physician.  
 
 
  You have been asked to pay a $20 copayment for the duplex scan. Duplex scan fall 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 a duplex scan (93880) provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional electrical stimulator supplies, 2 lead, per 
month (A4595). 
 
You asked the Plan to pre-approve additional electrical stimulator supplies. You say that you need more than 
the 24 count that was approved due to having multiple sclerosis and muscle spasms. The Plan denied your 
request. The Plan says the request over the allowed amount is deemed not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulator supplies have not been met. Specifically, the request for additional supplies 
over the allowed amount of 2 units is not covered. Therefore, we decided that the Plan does not have to pre-
approve additional electrical stimulator supplies, 2 lead, per month (A4595).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed. 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a fixed height hospital bed (E0250, E0251, E0290, 
E0291, and E0328) is covered if specific criteria are met. 
 
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 heavy-duty hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the hospital bed, heavy-duty, extra wide at issue in this case 
meets Medicare's Local Coverage Determination (LCD): Hospital Beds And Accessories - L33820 criteria for 
medically reasonable and necessary. Provided records of August 2, 2022 document that you weigh 209 pounds; 
as stated in the LCD: "A heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets 
one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does 
not exceed 600 pounds." 
 
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 heavy-duty hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a heavy-duty hospital bed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this 
large 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 $275 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $275 for these 
services. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance services.