Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on July 6, 
2021, and July 7, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there was a determination to remove the 
diagnosis codes A41.9 and R65.20. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes A41.9 and R65.20. 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that in this case, there was no clinical or laboratory evidence of sepsis. The review 
has determined that the records did not support the use of diagnosis code A41.9 (sepsis, unspecified organism) 
in this case. The records did not support the use of diagnosis R65.20 (severe sepsis without septic shock) in this 
case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee on July 6, 2021, and July 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy office visit provided on February 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy office visit. You say that you had a crisis, and you should not be 
charged. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 psychotherapy office visit provided on February 
14, 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 procedure codes S1015 and S8301 billed for date of service 
June 7, 2022. 
 
You asked the Plan to pay for procedure codes S1015 and S8301. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes S1015 and S8301 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes S1015 and S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes S1015 and S8301 billed for 
date of service June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0402, G0463, 36415) provided on June 2, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, codes 
G0402 and G0463 return OCE edit 42 when billed on the same day with the same revenue code without condition code G0. As such, the entire claim is denied, which means that code 36415 is also not covered. 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 services (G0402, G0463, 36415) provided on June 2, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25605 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 25605. You say that this should be paid for. 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 25605 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 25605 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 25605 billed for date of service March 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
5, 2022, to May 4, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says an NOA is required to process the claim. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an NOA is 
required to process the claim. Review of the file does not support that an NOA was submitted. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from April 5, 
2022, to May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 28, 2022, billed with 
codes 81162, 81295, 81298 and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary as the 
enrollee has a family history of cancer. The Plan denied your request. The Plan says panel testing should be 
billed using one CPT code on the claim. In addition, this panel was not medically necessary. 
 
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 
April 28, 2022, billed with codes 81162, 81295, 81298 and 81317.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency dental care provided on May 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency dental care provided on May 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the emergency department visit provided April 5, 
2022, while outside of the United States. 
 
You asked the Plan to reimburse you for the emergency visit. You say that while overseas in the Philippines, 
you had to go to the emergency room. Your credit card was charged $338.00. The Plan denied your request. 
The Plan says the services performed in the Philippines were not authorized by the Plan and proof of payment 
was not received. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.  The Plan offers an urgent care benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Health Plan contract says that you must submit proof of payment if you receive urgent care while outside 
of the U.S. and its territories. You will be responsible to pay for the services rendered upfront. In this case, the 
records show that proof of payment was needed. The Plan made multiple attempts to obtain the proof of 
payment for the services. We looked at the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency visit have not been met. Therefore, we decided that the Plan 
does not have to reimburse you for the emergency department visit provided April 5, 2022, while outside of the 
United States.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular stress test and a PET scan 
provided on April 22, 2021. 
 
You asked the Plan to waive the copayment for a stress test and PET scan. You say that someone told you that 
you would only owe $52.59. 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 $10 
copayment for Medicare-covered diagnostic tests and procedures, including stress tests.  The Plan contract also 
says that enrollees must pay a $245 copayment for Medicare-covered diagnostic radiology services (e.g, 
MRI/MRA, CT scans, nuclear cardiology tests). 
 
 You have been asked to pay a $10 copayment for the cardiovascular stress test. You have also been asked to 
pay a $235 copayment for the PET scan which is less that the standard copayment. You have been asked to pay 
a total of $245 ($10 + $235 = $245). These items/services 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 
cardiovascular stress test and a positron emission tomography (PET) scan provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 01, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of our plan, the enrollee must use network providers. If the enrollee 
receives unauthorized care (e.g., their provider does not receive an approved prior authorization) from an out-
of-network provider, we may deny coverage and the enrollee will be responsible for the entire cost. 
 
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 office visit provided on March 01, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 86077. You say that you have provided medical records to 
support the need for the additional unit of this code. 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 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
an injection provided on May 12, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for a specialist office visit and an injection. You 
say that you are not able to afford it based on your current income. 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 $40 
copayment for in network physician/practitioner services/specialist visit and a 20% coinsurance for in-network 
Medicare Part B prescription drugs.  
 
You have been asked to pay a $40 copayment for a specialist office visit and a 20% coinsurance for an 
injection. This item/service falls within the in-network physician/practitioner services/specialist visit and in-network Medicare Part B prescription drugs benefit category. The total amount you are being asked to pay is 
$41.18 (5.92 x 20% = $1.18) ($40 + 1.18=$41.18). 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 and 
coinsurance for a specialist office visit and an injection provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visits provided on June 9, 2022, to July 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic visits. You say that you pay your coinsurance, and this provider is 
better for you. 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 chiropractic visits provided on June 9, 2022, to 
July 10, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 17, 2022, to 
April 13, 2022. 
 
You asked the Plan to pay for the home health 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 all HHAs must submit a NOA at the beginning 
of the initial 30-day period of care. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted at the beginning 
of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from January 17, 2022, to April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adult transport chair provided on May 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the adult transport chair. The Plan denied your request. The Plan says this 
provider is out-of-network. 
 
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 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 adult transport chair provided on May 18, 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 laboratory services (0202U) provided on February 23, 
2022. 
 
You asked the Plan to pay for procedure code 0202U. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Medicare does not provide coverage for procedure code 0202U. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (0202U) provided on 
February 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on December 3, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you had fallen in your home. You say that 
you needed someone to help you up. You also say that you feel you should not be responsible for this bill. The 
Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
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 December 3, 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 the ambulance response and treatment, no 
transport, (A0998) provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0037U) provided on May 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab services (0037U) provided 
on May 3, 2022.