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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
July 14, 2023, to July 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost share is 
wrong 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 $295 
copayment for inpatient hospital services.. 
 
You have been asked to pay a $295 copayment for the inpatient hospital services. This item/service falls within 
the inpatient hospital 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. You are responsible for $885 ($295 x 3 days). You were not charged a copay for the day 
of discharge. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital services provided on July 14, 2023, to July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on August 
25, 2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that the cost share is wrong. 
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 $260 
copayment for outpatient surgery. 
 
You have been asked to pay a $260 copayment for the outpatient surgery. This item/service falls within the 
outpatient surgery 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 outpatient 
surgery provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 4, 2021, billed with 
procedure code 99213-25. 
 
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 documentation does not support the billed code. 
 
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 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that generally, whirlpool is a component 
of procedure codes 97597/97598 and should not be reported separately during the same encounter. Only when 
there is a separately identifiable service being treated by the therapist, and the documentation supports this 
treatment, would the service be considered for payment utilizing modifier -59 or a more specific modifier as appropriate (e.g., LT, RT, -XS, etc.). 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 4, 2021, billed with procedure code 
99213-25.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, and 87798 provided 
on July 6, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, and 87798. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed. 
 
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 procedure codes 87481, 87640, 87653, and 87798 provided on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (A4239) provided on July 24, 2023. 
 
You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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. In this case, the CPT Code Manual definition of 
code A4239 is ""Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), 
includes all supplies and accessories, 1 month supply = 1 unit of service." 
 
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 monitor. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee was prescribed a 
continuous glucose monitor to help with blood glucose control. The enrollee uses both insulin and Jardiance. 
The records show that the monitor was delivered to the enrollee's mailbox., and the enrollee saw the provider 
on July 7, 2022, October 21, 2022, and February 3, 2023. 
 
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 monitor have been met. Therefore, we decided that the Plan has to pay for a 
continuous glucose monitor (A4239) provided on July 24, 2023.  
 
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 lab services provided on May 5, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), and core buildup, 
including any pins when required (D2950) provided on May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the enrollee switched plans and you are not in-
network with the plan. You also say that you were not aware the enrollee had switched plans. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by the supplemental benefits.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows the enrollee received the requested dental services from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for the crown - porcelain/ceramic (D2740), and core buildup, including any pins when required 
(D2950) provided on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
September 05, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the cost share is wrong. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician 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 the specialist office 
visit provided on September 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
July 21, 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 ordering a multiclass panel of definitive (confirmation) urine drug tests that are not used in 
clinical management, exceeds the 
needs of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that although definitive testing for tramadol (1 class) was reasonable in this clinical situation, the 
documentation does not support the patient requiring more drug classes as there was no documented signs of 
likely abuse/misuse or a list of any other drugs taken that require screening. Therefore, the 22+ drug class 
definitive testing is excessive and will be considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) rendered on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99308 performed on July 27, 2022. 
 
You asked the Plan to pay for 99308. You say that 99308 should be paid as billed because it was medically 
necessary and is supported in the documentation. The Plan denied your request. The Plan says 99308 is denied 
because it was billed with an inappropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans, physicians, hospitals, and other 
health care providers must comply with the Official International Classification of Disease, 10th Edition, 
Clinical Modification (ICD-10-CM) Coding Guidelines. The rules also say that the coding of sequela generally 
requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. 
The sequela code is sequenced second. 
 
We looked at the file and Medicare rules. In this case, we confirmed that diagnosis code S71.002S, defined as 
unspecified open wound, left hip, sequela, was reported as the primary diagnosis code on the claim for 99308. 
The coding of sequela requires the condition or nature of the sequela to be sequenced first, followed by the 
sequela code. As S71.002S is a sequela code and is listed as the first and primary diagnosis on the claim in 
question, the condition or nature of the sequela was not sequenced first as required. We also confirmed that in 
this case, the sequela code was not followed by a manifestation code and the sequela code has not been 
expanded to include any manifestations. Based on this information, we decided that Medicare rules for 
coverage of 99308 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services described by code 99308 performed on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF is able to provide the level of care needed to 
treat the your condition. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, but skilled therapies as an outpatient or at a skilled nursing facility (SNF) may be approved upon 
request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on April 27, 2023, 
through May 3, 2023. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the inpatient services should be paid 
as billed because all diagnoses on the claim have POA indicators assigned. The Plan denied your request. The 
Plan says the inpatient services are denied because two of the diagnosis codes on the claim have incorrect POA 
indicators assigned.  
 
The Plan must follow Medicare rules. Medicare rules say that diagnoses which are exempt from POA reporting 
and should be reported with a POA indicator of 1 to indicate they are exempt.  
We looked at the file and Medicare rules. In this case, we confirmed that diagnosis codes Z86.711 (personal 
history of pulmonary embolism) and Z86.718 (personal history of other venous thrombosis and embolism) are 
listed diagnoses on the inpatient hospital services claim. Z86.711 and Z86.718 are both on the list of diagnosis 
codes which are considered POA exempt. Per Medicare rules, a POA exempt code should be reported with a 
POA indicator of 1 to show they are exempt. We confirmed that on the claim in question, Z86.711 and Z86.718 
were instead assigned a POA indicator of Y. As such, the denial of the inpatient hospital services is 
appropriate. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital 
services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services provided on April 27, 2023, through May 3, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81218, 81209, and 81272. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 81162, 81201, 
81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334.  
 
You asked the Plan to pay for procedure codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, and 81334 provided on June 16, 2023. You say that you would like the Plan to reconsider their denial of 
payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81218, 81209, and 
81272.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81218, 81209, and 81272.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334. 
 
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 81162, 81201, 81292, 
81295, 81298, 81307, 81317, 81321, 81351, and 81334 have not been met. Therefore, we decided that the Plan 
does not have to pay for the services described by procedure code(s) 81162, 81201, 81292, 81295, 81298, 
81307, 81317, 81321, 81351, and 81334. 
 
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 office visit provided on June 30, 2023. 
 
You asked the Plan to pay for the office visit. You say that the claim should be 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 June 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
June 09, 2023, to June 12, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the cost share is 
wrong. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for the emergency room services. 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 
services provided on June 09, 2023, to June 12, 2023.