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

 
We decided that the Plan does not have to increase the reimbursement for the copayment for an office visit and 
electrocardiogram (ECG) on March 16, 2023. 
 
You asked the Plan to increase the reimbursement for the copayment for an office visit and ECG. You say that 
that you paid the provider in full, and you were only reimbursed $117.74, and you would like to be reimbursed 
$67.26 for the remainder of the amount that you paid to the provider. 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 $0 
copayment for out-of-network provider and professional services at primary care providers (PCP) office. 
Covered services include medically necessary medical care or surgery services furnished in a physicians 
office, certified ambulatory surgical center, hospital outpatient department, or any other location. The records 
show you were reimbursed the full Medicare allowed amount with no applicable cost share. You were 
reimbursed $101.34 for the office visit and $16.40 for the electrocardiogram. You were reimbursed a total of 
$117.74. 
 
You have been asked to pay a $0 copayment for an office visit and ECG. This item/service falls within the 
physician/practitioner services, including doctor's 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 increase the reimbursement for the copayment for an office visit and electrocardiogram (ECG) on March 16, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85025, 84270, 36415, ,84403 and 
80053) provided on March 15, 2023. 
 You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says there are billing errors on this 
claim which must be corrected for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. The rules also say that a "code also" note indicates that two codes 
may be required to fully describe a condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the primary diagnosis listed on this claim 
(Z79.890) has a code also note to be reported with a Z51.81 code. In addition, this claim was reported with 
codes E23.0 and E29.1. However, codes within the E29 code set have an Excludes1 note with code E23.0. 
Therefore, we decided that the Plan does not have to pay for laboratory services (85025, 84270, 36415, ,84403 
and 80053) provided on March 15, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the preventive medicine counseling (99402) provided January 5, 2023. 
 
You asked the Plan to pay for the office visit. You say that you had a referral your primary physician and had 
been seen there several times in the past. The Plan denied your request. The Plan says that this service is not 
covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the office visit by a contract provider. The file does not show that the Plan provided 
notice that the office visit would not be covered. Under Medicare rules, this means the office visit is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the preventive medicine counseling 
(99402) provided January 5, 2023.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service January 6, 2023, 
to January 30, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 January 6, 2023. The NOA was not received by the Plan. 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 the home health services for date of service 
January 6, 2023, to January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on September 12, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 allowed amount for the DME is $556.20. You are being asked to 
pay $111.24 ($556.20 x 20% = $111.24). Therefore, we decided that the Plan does not have to waive the 
coinsurance for durable medical equipment (DME) provided on September 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) used in an 
ambulatory surgical center on March 8, 2023.  
 
You asked the Plan to pay for the PCD. You say that this should be paid separately as the surgical center 
cannot bill for this equipment and has indicated they did not receive payment for the services at issue. The Plan 
denied your request. The Plan says this is not a covered service under Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service and noncovered. The rules 
also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (PCD) used in an ambulatory surgical center on March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral upper eyelid blepharoplasty (15823). 
 
You asked the Plan to pre-approve the service. You say that you were diagnosed with dermatochalasis of both 
upper eyelids, and this impacts daily life. You state that your eyelids are swollen every morning.  The Plan 
denied your request. The Plan says the blepharoplasty is not medically necessary. The Plan says the 
documentation does not indicate any functional impairment in activities of daily living. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical notes do not clearly document details of how your symptoms affect functional 
activities of daily living. Color photos submitted of frontal view had gaze upward, thus, unable to fully evaluate lid margins. Other photos submitted does not show upper eyelid skin resting on eyelashes nor over eyelid 
margin. It did not demonstrate excessive dermatochalais pushing the eyelid margin down to an abnormally low 
position. The service is not medically necessary based on the records provided. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bilateral upper eyelid blepharoplasty (15823).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on March 23, 2023, billed 
with codes 87481, 87640, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. 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 a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The laboratory panel tests at issue were not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
testing provided on March 23, 2023, billed with codes 87481, 87640, 87653 and 87798.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from May 1, 
2022, to May 6, 2022.  
 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 records do not support the coding.  
 
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 services. Our physician reviewer found 
the Health Plans denial should be upheld.  While the enrollee was noted to have a history of non-specific 
colitis, there is insufficient evidence to support a specific diagnosis of Ulcerative Colitis, Crohns Disease or 
Inflammatory Bowel Disease. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services rendered from May 1, 2022, to May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT genetics testing (81455) provided on January 
9, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on not medically 
necessary or non-covered service status is not justifiable in this instance. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the Tempus xT genetics testing (81455) provided 
on January 9, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic visit (G0463) provided on November 30, 2022. 
 
You asked the Plan to pay for the visit. 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 hospitals subject to the Outpatient Prospective 
Payment System (OPPS) report Condition Code G0 when multiple medical visits occurred on the same day in the same revenue center, but the visits were distinct and constituted independent visits.  
 
We looked at the file and Medicare rules. In this case, two visits were provided on the same date of service 
without Condition Code G0. This returned OCE edit 42 which denies the claim. Based on this information, we 
decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the clinic visit (G0463) provided on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with codes A4450, A6252, and A6446 for 
December 14, 2022. 
 
You asked the Plan to pay for these services. You say that the services are separately billable. The Plan denied 
your request. The Plan says payment is included in the SNF consolidated payment. 
 
The Plan must follow Medicare rules. The rules say that durable medical equipment and supplies rendered to 
inpatients of a skilled nursing facility (SNF) is covered as part of the prospective payment system and is not 
separately payable.  
 
We looked at the file and Medicare rules. The file shows that the supplies were rendered to a SNF inpatient. 
Payment for these services is included in the SNF consolidated payment. Therefore, we decided that the Plan 
does not have to pay for the supplies billed with codes A4450, A6252, and A6446 for December 14, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 27602, 34151 and 34201 billed for date of service 
June 14, 2022. 
 
You asked the Plan to pay for procedure codes 27602, 34151 and 34201. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that these services are not supported in the 
medical record. 
 
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 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 procedure codes 27602, 34151 and 34201. Our reviewer says 
that these codes are supported for billing in this case. Our reviewer found that the medical record supports the 
use of procedure codes 34151, 34201 and 27602. The documentation states, performed midline laparotomy 
incision from the subxiphoid to just above the umbilicus. Ran entire bowel, a transverse arteriotomy incision 
was created immediately there was noted to be thrombus. In addition, the records state, performed below the 
knee popliteal incision dissecting out the popliteal artery to its bifurcation to the TP and AT branches. Similar 
fashion right leg was also thrombectomized for organized thrombus, and I decided to proceed with 
fasciotomies in order to avoid another trip to the operating room (OR) and prevent compartment syndrome We 
performed 4 compartment "fasciotomies. Therefore, these codes are supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 27602, 34151 and 34201 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 27602, 34151 and 34201 billed for date of service June 14, 
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 the advanced care planning provided on February 21, 2023, 
by an OON provider.  
 
You asked the Plan to pay for the advanced care planning. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
 
 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 advanced care planning provided on February 
21, 2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 4, 
2023, through March 6, 2023. 
 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 
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 these services. 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 presented to the emergency department (ED) after an implantable cardioverter-
defibrillator (ICD) firing caused lightheadedness while walking up the stairs. The enrollee reported no loss of 
consciousness. He was started on intravenous amiodarone and was later switched to oral medication. The 
workup was otherwise unremarkable. The enrollee was hemodynamically stable and did not have any persistent 
symptoms at the time of admission. Based on the stability of the enrollee and low complexity of the clinical 
situation, it was not expected that the enrollee would require hospital care that would have likely crossed two 
midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from March 4, 2023, through March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF guidelines/criteria and 
needs an interdisciplinary team approach that a lower level of care cannot provide. The Plan denied your 
request. The Plan says  the enrollee does not meet the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the 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 an IRF admission and services.