Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for emergency room services and inpatient 
hospital stay on November 11, 2022, to November 22, 2022.  
 
You asked the Plan to waive the cost share for emergency room services and inpatient hospital stay. You say 
that you want to appeal the amount being charged. 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 $90 
copayment per visit for emergency care. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. 
You must pay a $250 copayment per day for days 1-7 per admission for inpatient hospital stay. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. The day 
before you are discharged is your last inpatient day. For the first seven days there is a copayment. 7 x $250 = 
$1,750. For both services it's $90 + $1,750 = $1,840. Therefore, results in the total cost sharing amount of 
$1,840. 
 
You have been asked to pay a $90 copayment for emergency room services and a $250 copayment each day for 
inpatient hospital stay. This item/service falls within the emergency care and inpatient hospital 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 cost share for emergency room services and inpatient hospital 
stay on November 11, 2022, to November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (83520, 87798) provided on March 4, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 
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 83520 and 87798 are not supported in the medical record. Specifically, the lab order/requisition does not indicate exactly what tests were ordered to support the billed codes. 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 the lab services (83520, 87798) provided on March 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (U0004, U0005) provided January 28, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that your claims clearinghouse shows that the 
original claim submission date was prior to the timely filing deadline. The Plan denied your request. The Plan 
says the claim was received after the timely filing limitation. 
 
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 laboratory service was not filed until April 26, 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 the laboratory service (U0004, U0005) provided January 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87631, U0004, U0005) provided 
March 1, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denial and the 
provided records support the necessity of the service in dispute. The Plan denied your request. The Plan says 
this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 13, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (87631, U0004, U0005) 
provided March 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services received on February 24, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says a corrected claim is needed in order to reprocess the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly, with the 
correct type of bill. 
 
We find that these home health services are not supported in the medical record. Specifically, type of bill 322 is 
not valid for this claim, as the 4th digit of the type of bill must be 9 for home health claims. 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 home health services received on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service March 21, 
2023.   
You asked the Plan to pay for procedure code 99223. You say that this service was medically necessary. 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 code 99223 is 1. The MAI value for this code is 3. You billed 2 units of this 
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 99223 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99223 billed for date of service March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found genicular RFA is considered 
experimental in nature for the treatment of knee pain. The services are not reasonable or medically necessary 
for the enrollee. 
 
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 pre-approve genicular radiofrequency ablation (RFA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that more visits are needed due to the 
enrollee's medical condition with multiple factors involved. The Plan denied your request. The Plan says the 
requested services are not medically reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the member has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are not medically 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 24, 2023, billed 
with codes 87481, 87491, 87500, 87511, 87556, 87591, 87661, 87640, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting reconsideration and 
payment in full for the test performed 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. Also, review of the medical literature and clinical practice guidelines, including by the Infectious 
Disease Society of America and Healthcare Infection Control Practices Advisory Committee (HICPAC), state 
standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture and 
susceptibility studies. In addition, there is lack of support for the clinical utility of large multiplex PCR urinary 
tract infection panel tests. 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 February 24, 2023, billed with codes 87481, 87491, 87500, 87511, 87556, 87591, 
87661, 87640, 87653, 87798, and 87801.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for code Q0092. We decided that the Plan does not have to pay for code 
R0070.  
 
You asked the Plan to pay for code R0070, defined as the transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen, and code Q0092, defined 
as set up of portable x-ray equipment.. You say that codes R0070 and Q0092 should be paid as billed because 
documentation includes a portable x-ray order, report, and the reason a portable x-ray was needed. The Plan 
says that codes R0070 and Q0092 are not supported in the documentation. 
 
We decided that the Plan has to pay for code Q0092.  
 
The rules say that for portable x-ray services, carriers must pay a set-up component for each radiologic 
procedure (other than retakes of the same procedure) during both single patient and multiple patient trips under 
Level II HCPCS code Q0092. 
 
Records support that a portable x-ray service was done.  Therefore, we decided that the Plan has to pay for 
code Q0092.  
 
We also decided that the Plan does not have to pay for code R0070. 
 
The rules say that for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. No transportation charge is payable 
unless the portable x-ray equipment used was actually transported to the location where the x-ray was taken. 
 
Records do not contain any documentation of the transportation of portable x-ray equipment and personnel to 
the location where the x-ray services were provided. Therefore, we decided that the Plan does not have to pay 
for code R0070. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested HFCWOD is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested HFCWOD. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 a HFCWOD. Our reviewer says that the 
enrollee does not meet criteria for the requested HFCWOD. Our physician reviewer found the record indicates 
that the enrollee has chronic obstructive pulmonary disease. The record provided does not document the 
presence of bronchiectasis confirmed by computed tomography (CT) scan. The requested service is not 
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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services rendered from December 30, 2022, to 
January 25, 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 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 December 30, 2022. The NOA was not received by the Plan until May 16, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services rendered 
from December 30, 2022, to January 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve the skilled nursing services. You say that the enrollee was visiting her 
daughter out of town and became ill and was hospitalized. The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee has been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health 
services are not medically 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service May 3, 2023.  
 
  You asked the Plan to pay for procedure code 99239. You say that the enrollee was discharged and returned on 
the same day. You say that the medical records should be reviewed, and the coding is correct for each 
encounter. The Plan denied your request. The Plan says payment for code 99239 is bundled into payment for 
code 99223. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99239 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99239 billed for date of service May 3, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s): Remicade, Inflectra, OR infliximab; AND Stelara. The Plan states there is no indication the Plan's preferred drug(s) would 
likely be: less effective, and/or cause adverse effects for the enrollee. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our physician reviewer found 
the Plan requires a trial of drug Remicade, Inflectra OR Infliximab; AND Stelara, before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ilumya (J3245).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0425, A0427) provided on 
February 16, 2023.  
You asked the Plan to pay for ambulance transportation. You say that you are requesting reconsideration due to 
denial of claim. The Plan denied your request. The Plan says on the date of service, the enrollee was in an 
inpatient hospital status. 
 
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 A0425, A0427 are not supported in the medical record. Specifically, the records show 
that the enrollee was inpatient from February 15, 2023, to February 17, 2023. Medicare rules say that 
ambulance services used for transportation of a hospital inpatient to another facility is considered part of the 
inpatient admission and is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of ambulance transportation have not been met. Therefore, we decided that the Plan does not have 
to pay for ambulance transportation (A0425, A0427) provided on February 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5102 billed for date of service January 2, 
2023, to February 27, 2023. 
 
You asked the Plan to pay for procedure code S5102. You did not provide a specific argument with your appeal 
request. 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 S5102 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5102 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5102 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5102 billed for date of service January 2, 2023, to February 27, 2023.