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

 
We decided that the Plan does not have to pay for lab services provided on November 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and this 
claim should be paid. 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 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 November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on January 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. In this case, we have confirmed that code 71045 
is a column II code to column I code 32555. 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 the services (71045) provided on January 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services billed with code 88361 for date of service June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and the 
Plan has underpaid the claim. The Plan denied your request. The Plan says that this service code was originally 
submitted with multiple units and was split for processing. The individual units have been considered 
separately and the claim adjudications may appear on multiple Explanations of Benefits. 
 
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 was simply a quote of the denial 
message on the claim itself: "This service code was originally submitted with multiple units and was split for 
processing. The individual units have been considered separately and the claim adjudications may appear on 
multiple Explanations of Benefits."  The Plan has provided zero explanation for this or any documentation to 
support this.  The Plan has failed to provide any evidence of this claim being 'split' or any other claims or 
Explanations of Benefits that may have resulted from said 'split'.  The burden is on the Plan to show why its 
denial is appropriate.  The Plan has failed to do so here. Therefore, we decided that the Plan has to pay for lab 
services billed with code 88361 for date of service June 21, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for Colonoscopy on February 10, 2022. 
 
You asked the Plan to waive the copayment for Colonoscopy. You say that this was preventative and should 
have no copay. The Plan denied your request. The Plan says that Medicare-covered diagnostic procedures/tests: 
$0-$100 copay. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copay for Diagnostic Bone Mass Measurement, 
Diagnostic Colonoscopy and Diagnostic Mammography test performed on the same date of service as the 
corresponding preventive test. $100 copay for all other services.  
 
The Plan says you must pay a $100 copayment for Colonoscopy. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for Colonoscopy. Therefore, we decided that the Plan has to 
waive the copayment for Colonoscopy on February 10, 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 a domiciliary or rest home visit provided on December 10, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the 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 a domiciliary or rest home visit provided on 
December 10, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nebivolol tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has taken this drug for 
years with no issue. The Plan denied your request. The Plan says the denial of authorization for this drug is 
correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's 
Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nebivolol tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 September 5, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says no separate payment is made for this code. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
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 September 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when 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 epidural steroid injections. Our 
reviewer says that the services are not medically. Our physician reviewer found this is a common procedure 
performed by pain medicine specialists, there is no need to go out of network. The degree and duration of the 
second epidural steroid injection is unclear. The request is considered 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient hospital care on April 15, 2021, to 
April 21, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you had COVID related 
issues/hospitalizations, and it could be covered with no deductible or copay/coinsurance. The Plan denied your 
request. The Plan says for each Medicare-covered hospital admission/stay you pay $325 per day, days 1-6. $0 
for additional hospital days. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment for days 1-6 of inpatient hospital care. There were 6 total days, resulting in a total 
copayment amount of $1,950.00. 
 
 
 
 The enrollee has been asked to pay a $325 copayment for inpatient hospital care. Inpatient hospital care falls 
within the in-network inpatient hospital care benefits category. You have a $325 copayment for days 1-6. The 
provider billed the plan $29,696.01. The adjustments were $12,107.33. The plan paid $15,635.68. You have 
been asked to pay $1,950.00. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Inpatient 
hospital care on April 15, 2021, to April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay  durable medical equipment (L1851 and L2397). 
 
You asked the Plan to pay  this claim. You say that these items should be paid by the Plan. The Plan denied 
your request. The Plan says insufficient records were provided to support the services and items billed. 
 
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 
durable medical equipment (L1851 and L2397) have been met. Therefore, we decided that the Plan does not 
have to pay  durable medical equipment (L1851 and L2397).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient stay provided on February 26, 
2022, through February 28, 2022. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that the equipment for your heart didn't 
work right so you shouldn't be charged the copayment. The Plan denied your request. The Plan says the 
deductible had been met at the time the claim was received and the copayment applied 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 $300 
copayment per admission after the deductible is met for each medically necessary inpatient stay.  
 
 
 
 
 You have been asked to pay $300 copayment for inpatient stay. 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 inpatient stay provided on 
February 26, 2022, through 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 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 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on October 15, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance was the safest transport for 
the enrollee. The Plan denied your request. The Plan says the non-emergency ambulance services were not 
medically necessary. 
 
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 indicates that the enrollee was transported with stable vitals and without any treatment. 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 the documentation does not support that the ambulance transport on the date of service in this 
case was medically reasonable and 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) and 
ground mileage (A0425) provided on October 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF. You say that the records provided support the need for SNF care. The 
Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for admission 
to a SNF level of care, as he does not have a need for skilled therapy on a daily basis. The Plan says that the 
enrollee's therapy can be received at an alternate level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF. Our reviewer says that the criteria 
for coverage have not been met. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees condition.  
The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided 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 SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection services. 
 
You asked the Plan to pre-approve repeat epidural steroid injection services. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESIs may be considered medically 
reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline using the same scale for at least three months. 
 
We looked at the file and Medicare rules. In this case the documentation supports that, although the initial ESI 
provided pain relief, the relief was short lived, and the pain is back. There is no documentation that the 
requested repeat ESI is to utilize a different approach. Based on this information, we decided that Medicare 
rules for coverage of repeat epidural steroid injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 2, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the 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 a domiciliary or rest home visit provided on 
November 2, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response provided on January 21, 2022. 
 
You asked the Plan to pay for response without transport. You say that this bill should be covered by the Plan. 
The Plan denied your request. The Plan says ambulance response without transport is 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 January 21, 2022. 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 ambulance response 
provided on January 21, 2022.