Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of intrauterine device (IUD) (58301), insertion 
of IUD (58300), and levonorgestrel-releasing intrauterine contraceptive system (Mirena) (J7298) provided on 
March 10, 2022. 
 You asked the Plan to pay for the contraceptive services. You say that this has been covered in the past. You 
say that you do not understand why this is not covered now. You also say that you cannot afford to pay this 
bill. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
There was no documentation to show that this service is being requested to treat a specific illness/injury. As 
such, the Medicare rules for coverage of this procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the removal of intrauterine device (IUD) (58301), insertion of IUD (58300), and 
levonorgestrel-releasing intrauterine contraceptive system (Mirena) (J7298) provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided from 
April 16, 2022, to May 15, 2022. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you are asking for the 
plan to prorate the amount. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for an oxygen concentrator. The total allowed amount for the 
DME is $71.49. The amount you are being asked to pay is $14.30 ($71.49 x 20% = $14.30). 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 coinsurance for an oxygen concentrator provided from April 16, 2022, to May 15, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99153 billed for date of service April 12, 2022. 
 
You asked the Plan to pay for code 99153. You say that you did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says that the Place of Service (POS) billed was 
inappropriate for the procedure.  The Plan says that POS 21 should be used with services for patients in a Part 
A covered stay and POS code 32 should be used with services for patients in a noncovered stay. 
 
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. Specifically, the Plan's sole rationale for denial is that the POS is incorrect and 
either 31 or 32 should have been used.  This does not appear to make any sense in the context of the limited 
case file that the Plan submitted to us.  These were services rendered at a hospital.  There is no indication in 
any of the documentation provided to us that this patient was in a Skilled Nursing Facility (SNF) in either a 
covered or non-covered stay, so it is not clear why the Plan is asserting that the POS should be 31 or 32.  
Further, you billed with POS 21 (inpatient hospital).  It does appear from the limited records the Plan provided 
to us that these services were rendered in a hospital setting.  The burden is on the Plan to show why its denial 
was appropriate.  Without providing documentation to support its assertion of an incorrect POS code, we find 
that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for code 99153 billed for 
date of service April 12, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services billed for date of service January 18, 
2022. 
 
You asked the Plan to pay for the drug testing services. You say that the records support the billing of this 
service. The Plan denied your request. The Plan says the records provided do not support the billing of this 
service. 
 
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 the drug testing services have been met. Specifically, you billed for drug testing with a date of service of January 18, 2022.  While the visit note 
from that date of service does indicate that drug testing was performed, the only record of drug testing itself 
you provided was from date of service December 14, 2021.  You have not provided any results from any 
testing that may have been provided on January 18, 2022.  Without such records, we cannot confirm if this 
drug testing was performed and billed correctly. Therefore, we decided that the Plan does not have to pay for 
drug testing services billed for date of service January 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 72170. You say that you do not believe this is a bundled service. 
The Plan denied your request. The Plan says payment for code 72170 is bundled into payment for code 73502. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72170 is a column II code to column I code 73502. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72170 billed for date of service June 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), ground mileage (A0428), and ambulance waiting time (A0420) provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that any lesser mode of transport was 
contraindicated and may have compromised the enrollee's health and well-being. The Plan denied your request. 
The Plan says prior authorization was not obtained before the services were rendered. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not support the use of an advanced life support (ALS) ambulance or basic life support 
(BLS) ambulance. The reviewer found that the documentation does not support that other means of transport 
(such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the 
enrollee. The reviewer also found that he documentation does not support that the enrollee needed the 
expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Therefore, the reviewer found that the ambulance services were not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), ground 
mileage (A0428), and ambulance waiting time (A0420) provided on May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and an x-ray provided on July 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and an x-ray. You say that it was medically necessary for you to 
see the OON provider and you would like the Plan to cover the services. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and an x-ray provided on July 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department and related services (99283-25, 
87631-CS, 87798-CS, 87581-CS, and 87486-CS) provided on August 10, 2021. 
 
You asked the Plan to pay for the emergency department and related 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 87631, 87798, 87581, and 87486 are not 
eligible codes for the CS modifier to be billed as they are not on the coinsurance waiver eligible list. Medicare 
rules that the whole claim will be rejected and returned to the provider until the error is corrected. 
 
We looked at the file and Medicare rules. In this case, you have billed codes 87631, 87798, 87581, and 87486 
with the CS modifier. These codes are not on the coinsurance waiver eligible list. The required disposition for a 
claim with this edit is Return To Provider. This means the whole claim is returned to the provider. The provider 
can resubmit the claim once the problem is corrected. Based on this information, we decided that Medicare 
rules for coverage of the emergency department and related services have not been met. Therefore, we decided 
that the Plan does not have to pay for the emergency department and related services (99283-25, 87631-CS, 
87798-CS, 87581-CS, and 87486-CS) provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 17, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99053 is 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 code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammography on April 06, 2022. 
 
You asked the Plan to waive the copayment for mammography. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $75 
copayment for Medicare-covered radiological diagnostic services, not including X-rays. Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays (when the service is performed at a hospital, outpatient facility or a freestanding facility imaging or 
diagnostic center). 
 
 
 
 
 You have been asked to pay a $75 copayment for mammography. This item/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 mammography on April 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services provided on June 08, 
2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $150 copayment for outpatient services. This item/service falls within the 
Outpatient hospital services 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. You have been asked to pay $116.69 which is less than the standard $150 copayment for 
hospital services. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
services provided on June 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 3, 2022, billed with 
codes 81401, 81403, 81404, 81405, 81406, 81185, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 3, 2022, billed with codes 81401, 81403, 81404, 81405, 81406, 81185, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on July 28, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that the provider sent these labs to our facility, so this should 
be covered, since the provider is in network. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 lab work provided on July 28, 2022, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 27, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you shouldnt have to pay for 
this since it was a surgery to fix the first surgery. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $325 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $325 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in a hospital outpatient facility 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 outpatient surgery provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0481) provided on April 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (G0481) provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services provided on June 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit services. You say that the patient gave incorrect insurance 
information. The Plan denied your request. The Plan says a referral/authorization was not obtained prior to 
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 home visit services provided on June 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on June 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry 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 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 podiatry services provided on June 28, 2022, by an 
out-of-network (OON) provider.