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

 
We decided that the Plan does not have to pay for the office visit provided on May 10, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the service 
provided. 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 May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 03, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the service 
provided. 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 August 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 13, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that the enrollee had to return to 
the urgent care for the same issue. 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit provided on August 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87798 billed for date of service 
January 16, 2023.  
 
You asked the Plan to pay for procedure codes 87481 and 87798. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes 87481 and 87798 is 5 and 13, respectively. The MAI value for these 
codes is 3. You billed 6 and 23 units of these code, exceeding the MUE. You did not provide all the required 
evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 87481 
and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87481 and 87798 billed for date of service January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the annual eye exam provided on 
September 15, 2023. 
 
You asked the Plan to waive the copayment for the annual eye exam. You say that you were told that this 
provider was in-network. 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 vision care. 
 
You have been asked to pay a $15 copayment for the annual eye exam. This item/service falls within the vision 
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 annual eye exam provided on 
September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 29, 2023. 
 
You asked the Plan to pay for anesthesia services. 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 anesthesia services 
provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on September 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on June 29, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you do not agree with the denial of payment 
because you have already submitted medical records along with the required documents. The Plan denied your 
request. The Plan says you are not enrolled in Medicare as a durable medical equipment supplier.  
 
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 you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on June 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2023, to September 23, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that there arent any contracted providers in this 
patients geographic area able to provide home infusion therapy services for implanted intrathecal pumps. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2023, to September 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
November 22, 2021, to November 26, 2021, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the
DRG was billed correctly. The Plan denied your request. The Plan says that the billed diagnoses are not
supported in the medical record.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with diagnosis
code A41.9, defined as sepsis, unspecified organism and diagnosis code R65.20, defined as severe sepsis
without septic shock. Our Medical Director states that the enrollee had a medical history that included coronary
artery disease, diabetes, chronic kidney disease, and hypertension. He presented to the Emergency Department
with chest pain, abdominal pain, shortness of breath, and diaphoresis. Laboratory studies were notable for
white blood count of 23.0, a lactic acid of 4.4 and a creatinine of 1.9. A computed tomography scan
demonstrated opacities at the left lung base in addition to a band-like opacity, that represented atelectasis
and/or scarring. The clinical documentation does not support the diagnoses of A41.9 (Sepsis, unspecified
organism) and R65.20 (Severe sepsis without septic shock) using Sepsis-3 definitions. Our Medical Director
found that the enrollee's condition did not meet Medicare criteria for the inpatient hospital services provided
from November 22, 2021, to November 26, 2021, at the DRG originally billed.

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 provided to the enrollee from November 22, 2021, to November 26, 2021, at the
Diagnosis Related Group (DRG) originally billed.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 24, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were not related to the 
enrollee's hospice diagnosis, and they were medically necessary. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on July 20, 2023. 
 
You asked the Plan to pay for an outpatient visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider has opted out of Medicare. 
 
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 an 
outpatient visit provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 30, 2023, billed 
with procedure code 99204. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J30.1 has an Excludes1 note in relation to J31.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on August 30, 2023, billed with procedure code 99204.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 23, 2023. 
 
You asked the Plan to pay for a home visit. 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 a home visit provided on 
August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray and the office visit on July 29, 
2023.  
 
You asked the Plan to waive the copayments for the x-ray and the office visit. You say that the doctor is an in-
network doctor and that you should be charged the in-network rate. 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 each Medicare-covered standard x-ray service. You must pay a $40 copayment for services 
from a specialist or under certain circumstances, treatment by a nurse practitioner, physicians assistant or other 
non-physician health care professional in a specialists office (as allowed by Medicare). For both services it's 
$30 + $40 = $70.Therefore, results in the total cost sharing amount of $70. 
 
You have been asked to pay a $70 cost share for the x-ray and the office visit. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies and 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 copayments for the x-ray and the 
office visit on July 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) abdominal 
scan provided on July 20, 2023. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) abdominal scan. You say that 
your prime care provider ordered this, you would like the cost to be lowered. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) abdominal scan. 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. However, since the 
allowed amount is less than the standard copayment, you only owe $186.30. Therefore, we decided that the 
Plan does not have to reduce the copayment for a computed tomography (CT) abdominal scan provided on July 
20, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urgent care services provided on August 7, 2023. 
 
You asked the Plan to pay for the urgent care services. You say that your diagnosis for this urgent care visit 
was not the same as your hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for urgent care services provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on September 13, 
2023. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you had these services previously 
and didnt 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 $40 
copayment for vision services - routine eye exam. 
 
You have been asked to pay a $40 copayment for the eye exam. This item/service falls within the vision 
services - routine eye exam 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 eye 
exam provided on September 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 4, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The genetic testing provided in this case is not covered under the 
DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on February 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 01, 2023. 
 
You asked the Plan to pay for the office visit. You say that you would like the supporting documents and 
medical records to be reviewed and the claim to be reprocessed and paid. 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 May 01, 2023.