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

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 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 January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on February 03, 2023. 
 
You asked the Plan to pay for genetic 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 genetic laboratory 
testing provided on February 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a genetic test to be covered, the test must 
have satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services Program 
(MolDX) for the stated indications of the test. 
 
We looked at the file and Medicare rules. This test is not approved by MolDX for the enrollee's condition. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81162).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services on April 12, 2022, through May 11, 
2022. 
 You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 12, 2022. The NOA was not received by the Plan until July 6, 
2022. 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 on April 
12, 2022, through May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on February 
22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chronic care management services. You say that the enrollee was in a nursing 
home setting at the time services were rendered. The Plan denied your request. The Plan says enrollees must 
receive their care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chronic care management services provided on 
February 22, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021. 
 
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 August 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for dates of service from 
January 3, 2023, to January 20, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says procedure code 97010 is considered bundled and 
not separately payable.  
 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for dates of service from January 3, 2023, to January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network orthopedic visit provided on 
March 31, 2023. 
 
You asked the Plan to waive the copayment for an in-network orthopedic visit. You say that you should not 
have to pay a copay for this. The provider did nothing to help you, and only saw you for a few minutes. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an in-network orthopedic visit. This item/service falls within 
the 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 copayment for an in-network orthopedic visit provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nail debridement procedure provided on February 08, 2023. 
 
You asked the Plan to pay for a nail debridement procedure. 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 nail debridement 
procedure provided on February 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
October 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the document does not support this level of care. 
 
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, the CPT Code Manual definition of code Initial hospital care, per day, for the evaluation and 
management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation from this date 
describes the enrollee as having presented to the emergency department (ED) for an abnormal lab - low 
hemoglobin. The enrollee reported no weakness/lightheadedness or blood in the stool. There was no reported 
shortness of breath or chest pain, or other symptoms. Vitals were reported to be stable. It was noted that 
hemoglobin was 4.9. Exam findings were documented and were detailed but unremarkable. Although, the 
history and physical were a broadened focus, they each were not comprehensive. Also, the documentation 
failed to show that medical decision-making was of high complexity as the enrollee was stable and was treated 
only with fluids and blood transfusion. Therefore, CPT 99223 was not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment on November 04, 2022, 
to December 03, 2022.  
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you feel it was misleading to 
you, that the plan would approve medical equipment in October and lead you to believe they were 100% 
covered on this medical device and now default. 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 20% 
coinsurance of the Medicare-allowable amount for each Medicare-covered item for durable medical equipment 
(DME). Covered items include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, speech generating 
devices, oxygen equipment, nebulizers, and walkers. The allowed amount is $864.64 for the service. $864.64 x 
20% = $172.93. Therefore, results in the total cost sharing amount of $172.93. 
 
You have been asked to pay a 20% coinsurance for oxygen equipment. This item/service falls within the 
durable medical equipment (DME) and related 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. Therefore, we decided that the Plan does not have to waive 
the coinsurance for oxygen equipment on November 04, 2022, to December 03, 2022.
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 
March 23, 2023, to March 29, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not think you 
should be responsible for the 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 $325 
copayment per day, for days 1-5, for each inpatient stay. 
 
 You have been asked to pay a $1625 copayment for the inpatient hospital stay ($325 x 5 days = $1625). This 
item/service falls within the 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 
copayment for the inpatient hospital stay provided from March 23, 2023, to March 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network air ambulance provided on 
October 7, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network air ambulance. You say that there was a 
malware hack at the hospital you were at. No one discussed the ambulance or the cost with you and you're very 
upset about this. 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 20% 
coinsurance for ambulance services.  
 
The allowed amount of this air ambulance service is $4939.92, resulting in a coinsurance amount of $987.98 
($4939.92 x 20% = $987.98). You have been asked to pay a $987.98 coinsurance for an in-network air ambulance. This item/service falls 
within the ambulance 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 coinsurance for an in-
network air ambulance provided on October 7, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy (PT) services provided on July 21, 2022. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary and 
referred by the enrollee's dentist. The Plan denied your request. The Plan says that 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 pay for the therapy services. Our reviewer says that 
the service was medically necessary. Our physician reviewer found the requested physical therapy is generally 
accepted as a specific and effective therapy for TMJ dysfunction. The therapy performed required the skills of 
a physical therapist and was medically reasonable. 
 
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 been met. Therefore, we decided that the Plan has to 
pay for physical therapy (PT) services provided on July 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation Pain Index (FPI) testing provided on January 
10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the Foundation Pain Index (FPI) testing. You say that this is the only lab in the 
country that performs this test. The Plan denied your request. The Plan says enrollees must receive their care 
from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the Foundation Pain Index (FPI) testing provided on January 
10, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on February 21, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received out-of-network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The Plan has a POS 
benefit to cover certain out-of-network services. The Plan contract also says that out-of-network telehealth 
services are not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telehealth visit provided on February 21, 2023, 
by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with DRG 175 rendered 
from February 11, 2022, to February 13, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration. The Plan denied your request. The Plan says the DRG 
was updated. 
 
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 diagnosis code J96.01. 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 after admission and throughout the hospital stay, the enrollee was not noted to be in acute 
respiratory distress or have significant hypoxia (reduction of PaO2 of 10+ mmHg below baseline) to justify 
the diagnosis code J96.01 - acute respiratory failure with hypoxia. The enrollee did not require high flow 
oxygen support, BiPAP, or vent support. Therefore, the DRG 176 is more appropriate for this admission 
according to the provided records.   
 
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 billed with DRG 175 rendered from February 11, 2022, to February 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you believe the visit should be covered. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.