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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 28, 2022, and billed with codes 87900, 87899, 87798, 87653, 87652, 87640, 87500, and 
87481. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on July 28, 2022, and billed with codes 87900, 87899, 87798, 87653, 87652, 87640, 
87500, and 87481.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on January 25, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
January 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound scan of the uterus provided 
on September 23, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound scan of the uterus. You say that you do not 
understand the copayment applied to this service. 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 $185 
copayment for Medicare-covered radiological diagnostic services, which includes ultrasounds. 
 
You have been asked to pay a $185 copayment for an ultrasound scan of the uterus. This item/service falls within the Medicare-covered radiological diagnostic services, which includes ultrasounds 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. However, since the 
allowed amount is less than the standard copayment, you only owe $117.87. Therefore, we decided that the 
Plan does not have to waive the copayment for an ultrasound scan of the uterus provided on September 23, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 29, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on December 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 19, 2022, to 
September 17, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted medical records to 
support necessity. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 19, 2022. The NOA was not received by the Plan until September 
28, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 19, 2022, to September 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing provided on April 04, 2023. 
 
You asked the Plan to waive the copayment for lab testing. You say that you feel as though the lab work for 
this claim was routine and not diagnostic and therefore should not have to pay. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $15 copayment for lab testing. 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 lab testing provided on April 04, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each outpatient cardiac rehabilitation 
service provided on January 04, 2023, to January 09, 2023. 
 
You asked the Plan to waive the coinsurance for each outpatient cardiac rehabilitation service. You say that 
you were told that there would be no cost for these services. 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 40% 
coinsurance for out-of-network Medicare-covered cardiac rehabilitation services. 
 
You have been asked to pay 40% coinsurance for each outpatient cardiac rehabilitation service. This 
item/service falls within the out-of-network Medicare-covered cardiac rehabilitation 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. The total amount you owe 
is $127.08 ($317.73 allowed amount for 3 services x 40% = $127.08 rounded down). Therefore, we decided 
that the Plan does not have to waive the coinsurance for each outpatient cardiac rehabilitation service provided 
on January 04, 2023, to January 09, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from July 7, 
2021, to August 5, 2021. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that home health services are not supported in the case record. Specifically, no OASIS recertification 
has been provided. Based on this information, we decided that Medicare rules for coverage of home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
billed for dates of service from July 7, 2021, to August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing provided on January 27, 2023. 
 
You asked the Plan to waive the copayment for lab testing. You say that you say that no one ever told you that 
you would have to pay for any lab work. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for lab testing. 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 lab testing provided on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1852) suspension sleeve (L2397) 
provided January 13, 2023. 
 
You asked the Plan to pay for the orthoses. You say that it is not the responsibility of the DME to ensure that 
the referring physician submits a claim for their services. The Plan denied your request. The Plan says this 
service is not allowed because it was related to a prohibited telemarketing contact. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have 
not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1852) 
suspension sleeve (L2397) provided January 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 1, 2022, to 
November 22, 2022. 
 You asked the Plan to pay for the home health services. You say that you do not believe there are any errors 
with the NOA or the claim you submitted.  The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 1, 2022. The NOA was not received by the Plan until February 
2, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 1, 2022, to November 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on January 12, 2023, billed with 
codes 95938, 95861, 95865, 95868, 95937, and G0453. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. This claim was billed with diagnosis codes M54.2 
and M50.20 which is a diagnosis code pair that is subject to an Excludes1 note and cannot be billed together. Therefore, we decided that the Plan does not have to pay for testing services provided on January 12, 2023, 
billed with codes 95938, 95861, 95865, 95868, 95937, and G0453.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network oncology specialist visit 
provided on January 11, 2023. 
 
You asked the Plan to waive the copayment for an in-network oncology specialist visit. You say that you 
should not have this copayment. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for an in-network oncology specialist visit. This item/service 
falls within the physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network oncology specialist visit provided on January 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a  CPAP (continuous positive airway pressure) provided on 
March 27, 2023. 
 
You asked the Plan to pay for a  CPAP (continuous positive airway pressure). You say that you want this 
covered, it is too costly. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a  CPAP (continuous 
positive airway pressure) provided on March 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomogoraphy (CT) scan, thorax provided on 
November 10, 2022. 
 
You asked the Plan to pay for computed tomogoraphy (CT) scan, thorax. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for computed tomogoraphy 
(CT) scan, thorax provided on November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70490 and 71250 rendered on January 17, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents received do not support that these services were distinct or independent from 
other services performed. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 70490: 
 
Computed tomography, soft tissue neck; without contrast material 
 
CPT 71250: 
 
Computed tomography, thorax, diagnostic; without contrast material 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that positron emission 
tomography/computed tomography (PET/CT) was done on January 17, 2023. Separate charges for CPT 70490 
and 71250 were split off and billed as separate procedures. This represents unsupported unbundling of the 
PET/CT. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure codes 70490 and 71250 rendered on January 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 24, 2022, to 
October 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 24, 2022. The NOA was not received by the Plan until January 
18, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 24, 2022, to October 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services rendered from October 7, 
2022, to October 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's health and life would 
have been significantly and directly threatened if care was provided in a less intensive setting. The Plan denied your request. The Plan says there was no documentation of acute coronary syndrome, hemodynamic instability, 
or need for extensive cardiac testing that could not be completed as an outpatient/observation. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.Our 
physician reviewer found that the enrollee had new-onset stable atrial fibrillation. Patients with this clinical 
scenario can be managed in a less intensive setting, such as outpatient/observation. 
 
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 pay for acute inpatient hospital services rendered from October 7, 2022, to October 8, 
2022.