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

 
We decided that the Plan does not have to pay for an ECG provided on March 18, 2023, by an OON provider.  
 
You asked the Plan to pay for an ECG. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an ECG provided on March 18, 2023, by an OON 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87511, 87640, 87653, 87798, & 
87801) provided on January 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87500, 87511, 87640, 87653, 87798, & 87801 are not supported in the medical 
record. Specifically, multiple unbundled codes were billed for a single panel. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87481, 87500, 87511, 87640, 87653, 87798, & 87801) provided on 
January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 14, 2022, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81328, 81335, and 
81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 14, 2022, billed with codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 
81306, 81328, 81335, and 81479.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says admission to an LTACH does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Health Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office services (99213) provided on September 12, 2022. 
 
You asked the Plan to pay for the office services . You say that the other services billed, were labs under 
another National Provider Identifier (NPI). The Plan denied your request. The Plan says that this charge is 
included in the contracted and/or case rate and includes any concurrency reductions that may apply. No 
additional payment will be made for this service. 
 
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. Review of the file shows that the Plan did not substantiate their denial. The Plan 
did not show any other services billed with this office visit; therefore, we do not know if this is included in the 
payment/allowance for another service. Therefore, we decided that the Plan has to pay for the office services 
(99213) provided on September 12, 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 anesthesia for upper gastrointestinal endoscopic 
procedures, endoscope introduced proximal to duodenum; not otherwise specified (00731-QX-QS) provided on 
January 18, 2023. 
 
You asked the Plan to pay for the service. You say that the enrollee was transferred for the procedure. The Plan 
denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The enrollee was registered as an 
inpatient of a hospital; therefore, it is inappropriate to bill in an outpatient place of service. Therefore, we 
decided that the Plan does not have to pay for the anesthesia for upper gastrointestinal endoscopic procedures, 
endoscope introduced proximal to duodenum; not otherwise specified (00731-QX-QS) provided on January 18, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
March 09, 2023, to March 10, 2023. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that you should not have 
a 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room service. This item/service falls within 
the emergency 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 the emergency room 
service provided on March 09, 2023, to March 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on February 20, 2023. 
 
You asked the Plan to pay for the mental health services. You say that the provider is in-network with the Plan. 
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 mental health 
services provided on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient surgery provided on January 
24, 2023. 
 
You asked the Plan to waive the cost share for an outpatient surgery. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $226 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $226 
deductible which applies to outpatient surgery. You are being asked to pay $186.84 towards your $226 
deductible. This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery 
was received on January 24, 2023. Therefore, we decided that the Plan does not have to waive the cost share 
for an outpatient surgery provided on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 04, 2023. 
 
You asked the Plan to pay for lab services. You say that these 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 lab services provided on 
April 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on March 30, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 14, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. 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 testing 
provided on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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, for 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 October 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network audiometry and 
tympanometry test provided on January 18, 2023. 
 
You asked the Plan to waive the copayment for an in-network audiometry and tympanometry test. You say that 
this should have been a routine visit. 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 $45 
copayment for diagnostic hearing and balance evaluations. 
 
You have been asked to pay a $45 copayment for an in-network audiometry and tympanometry test. This 
item/service falls within the diagnostic hearing and balance evaluations 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 audiometry and tympanometry test provided on 
January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit provided on 
February 15, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visit. You say that you cannot afford the 
cost share. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to physician/practitioner services, 
including doctor's office visit. Your contract with the Plan also clearly says that you must pay 40% 
coinsurance, after your $750 deductible, for Medicare-covered physician specialist services. 
 
 
 You have been asked to pay $149.74 which satisfied the deductible for the specialist office visit. The remaining 
allowed amount, after the deductible has been met, is $17.48 ($167.22 allowed amount - $149.74 deductible = 
$ 17.48). The item or service you asked the Plan to waive the cost share for falls within the 
physician/practitioner services, including doctor's office visit benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $750 deductible which applies to physician/practitioner 
services, including doctor's office visit. This cost sharing is a contractual obligation that had not been met at the 
time the specialist office visit was received on February 15, 2023.  
 
You have also been asked to pay $6.99, which is 40% coinsurance of the remaining allowed amount for the 
specialist office visit ($17.48 remaining allowed amount x 40% = $6.99). This item/service falls within the 
physician/practitioner services, including doctor's office visit 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 cost share for the specialist office visit provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services ( 87150, 87481, 87798) provided on June 2, 
2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes  87150, 87481, & 87798 are not supported in the medical record. Specifically, multiple 
unbundled codes were billed for a single lab procedure. These services are included in CPT 87500 which was 
approved. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services ( 87150, 87481, 87798) 
provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 10, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this provider is a Medicare opt out provider and not eligible to be part 
of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 for date of service February 18, 2023. 
 
You asked the Plan to pay for procedure code 99239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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. Review of the file shows that code 99239 was billed with diagnosis 
codes R06.02 (Shortness of breath) and J96.01 (Acute respiratory failure with hypoxia). Due to an Excludes1 
note, these two diagnosis codes should not be billed together. The claim is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99239 for date of service February 
18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 10, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
payment. 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 office visit provided 
on January 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 26, 2022, to 
September 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 26, 2022, to 
September 24, 2022.