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

 
We decided that the Plan does not have to pay for laboratory services provided on April 21, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. 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 laboratory services 
provided on April 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 177 rendered 
from February 10, 2023, to February 13, 2023. 
 
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 diagnosis code N17.0 is not supported in the 
records, which results in a DRG downgrade from DRG 177 to DRG 179. 
 
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 DRG 177. 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 the enrollee had acute kidney injury but the urinalysis does not show tubular casts. Therefore it does not 
meet criteria for acute tubular necrosis and thus code N17.0 is not supported. The documentation supports 
DRG 179 rather than DRG 177.  
 
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 reported with DRG 177 rendered from February 10, 2023, to February 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005 and 94640 billed for date of service February 
20, 2023. 
 
You asked the Plan to pay for codes 93005 and 94640. You say that these services were medically necessary 
and provided in good faith. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, 
meaning they are STV-packaged services.  These disputed codes were billed on the same claim with a code that 
has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93005 and 94640 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 93005 and 94640 billed for date of service February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the requested cardiac catheterization is 
medically necessary. The Plan denied your request. The Plan says cardiac catheterization is medically needed if 
you have high risk findings on stress testing or if you are about to undergo high risk surgical procedures. You 
have not had high risk findings on a stress test, and you are not going to have high risk surgery. There are other 
tests that you can have to evaluate your heart arteries that are safer. 
 
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 cardiac catheterization. Our reviewer 
says that the requested cardiac catheterization is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that you have a history of occasional chest pains. A stress test was normal. The medical records provided do not support the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would 
not be considered medically appropriate and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services reported with DRG 280 rendered from 
December 1, 2022, to December 3, 2022. 
 
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 that they are upholding the reassignment of the 
DRG for this admission. 
 
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 DRG 280. 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 supported by the medical records. Our physician reviewer found that 
the enrollee had acute decompensation of chronic heart failure with an admission for NSTEMI, so code I50.23 
is justified. The documentation more supports DRG 280 rather than DRG 281. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services reported with DRG 280 rendered from December 1, 2022, to December 3, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 24, 2021. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the 
claim was untimely, and the submission did not meet the exception criteria guidelines outlined in 42 CFR 
424.44. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physical therapy services was not filed until February 2, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on  
December 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 4, 2022, to November 8, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this 
bill. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment per day for days 6-90 of each in-network inpatient hospital stay. You have been asked to pay a $325 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
four or for the day you were discharged. You have been asked to pay a total of $1,300 for the inpatient hospital 
stay ($325 copayment per day x 4 days = $1,300). 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 
the inpatient hospital stay provided from November 4, 2022, to November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96366 rendered on January 10, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered. 
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. 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 code 96366 rendered on January 
10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency clinic services (87086, 99000, 81003, 99283) 
provided on April 18, 2022. 
 
You asked the Plan to pay for the emergency clinic services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the provider was not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency clinic services (87086, 
99000, 81003, 99283) provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 rendered on 
March 27, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered. 
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. 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 96365, 96366, and 96521 
rendered on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 27, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the provider's office told you that they took 
your insurance Plan. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-
of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on February 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on March 17, 
2023. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation services (A0021-A0999, S0207-
S0215, S9960-S9961) are not separately payable from the payment to the inpatient institution. 
 
We looked at the file and Medicare rules. The enrollee was an inpatient at the time this service was provided. 
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 ambulance services (A0425, A0427) 
provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 16, 2023. 
 
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 March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 31, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this provider is your 
primary care 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 $40 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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 records show this provider is a specialist. Therefore, we 
decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 31, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on May 09, 2023. 
 
You asked the Plan to pay for the surgery 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 surgery services 
provided on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on April 21, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you thought this was considered a 
follow-up appointment. 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 specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the specialist 
physician/practitioner 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 record shows this claim was approved and you are responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the copayment for the office visit 
provided on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing for 22 or more drug classes (G0483) 
provided on February 21, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that the services were medically necessary. The 
Plan denied your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug 
tests that are not used in clinical management exceeds the needs of the enrollee.   
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 pay for procedure code G0483. Our reviewer says 
that the services were not medically necessary. Our physician reviewer found the enrollee has chronic neck and 
low back pain. She is taking Lyrica and oxycodone. There is no history of drug abuse or diversion, early refill 
requests or self-escalation. There was no qualitative screening done. A comprehensive 22 class test was 
performed. Since the LCD criteria were not met, the testing was not 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 procedure code G0483 have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing for 22 or more drug classes (G0483) provided on February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the request for Orthovisc is medically necessary.  
The Plan denied your request. The Plan says the request for Orthovisc is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Orthovisc. Our reviewer says that the 
request for Orthovisc is not medically necessary.  Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the shoulder. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.