Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 5, 2023, to 
September 11, 2023. 
 
You asked the Plan to pay for the home health services. You say that you believe you are an in-network 
provider. The Plan denied your request. The Plan says you billed the wrong Type of Bill code on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 Based on this rule, this claim should have been billed with Type of Bill code 0327 or 0329. Instead, you billed 
with Type of Bill code 0324, which is incorrect. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from September 5, 2023, to September 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 7, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the results allow physicians to make treatment 
decisions. The Plan denied your request. The Plan says this testing as a screening is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that an immunodeficiency genetic disease risk panel was provided. The testing at issue in this 
appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. 
Additionally, the panel was not billed with a single code as required. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab testing billed for date of service March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
from June 9, 2023, to June 28, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump (E0218). You say that this item was 
medically necessary. The Plan denied your request. The Plan says this item is not covered. The Plan must 
follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is not covered 
by Medicare. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad with 
pump (E0218) provided from June 9, 2023, to June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 21, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for 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 August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes K0040-NU-KX-KH and K0038-NU-KX-KH provided 
on October 2, 2023. 
 
You asked the Plan to pay for procedure codes K0040-NU-KX-KH and K0038-NU-KX-KH. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the 
services are not covered as billed. 
 
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. We find that the Plan has not provided enough evidence to support the denial of 
payment for procedure codes K0040-NU-KX-KH and K0038-NU-KX-KH based on Medicare criteria. The 
Plan has used local coverage article A52504 as the basis of their denial stating that these codes should be billed 
with the RT and LT modifiers. However, the article clearly states that the RT and LT modifiers are optional. 
Codes K0040 and K0038 were billed correctly in this case. As the Plan has provided no other rationale for the 
denial of these codes, we must find in your favor based on Medicare criteria. Therefore, we decided that the 
Plan has to pay for procedure codes K0040-NU-KX-KH and K0038-NU-KX-KH provided on October 2, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging provided on 
August 09, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging. You say that the service was 
unnecessary. 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 $85 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
You have been asked to pay a $85 copayment for a magnetic resonance imaging. 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. Therefore, we decided that the Plan does not have 
to waive the copayment for a magnetic resonance imaging provided on August 09, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular junction testing (95937) provided on July 
19, 2023. 
 
You asked the Plan to pay for the testing. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 95937, neuromuscular 
junction testing (repetitive stimulation, paired stimuli), each nerve, any one method was billed. Train of four 
testing doesn't fit the criteria for this code as it's inappropriate to bill the code for neuromuscular junction when 
train of four monitoring is performed.  
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. We asked our physician 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 testing. Our reviewer says that code 95937 was 
requested; however, the documentation describes the patient having train of four testing performed during the 
procedure which does not fit the above code and as this electrical stimulation testing is integral to the surgical 
procedure and is not separate. Therefore, the documentation does not support procedure code 95937. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the neuromuscular junction testing (95937) provided on July 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service January 1, 
2023, to January 11, 2023. 
 
You asked the Plan to pay for the billed services. You say that code 3CA31 is the correct code for this claim. 
The Plan denied your request. The Plan says an appropriate revenue code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. We find that HIPPS code 3CA31 was billed with revenue code 0022. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health care billed for dates of service 
January 1, 2023, to January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
March 12, 2023, to March 22, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that it is not your fault you 
got COVID and you do not think you should be responsible for the copayment for your stay. 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 $300 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $300 copayment for the inpatient hospital stay. This item/service falls within the in-network 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. You have been asked to pay $1,800, which is a $300 copayment for the first six 
days of the inpatient stay ($300 copayment x 6 days = $1,800). You were not charged beyond the sixth day. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay 
provided on March 12, 2023, to March 22, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit received on July 21, 2023, with an out-of-network 
provider. 
 
You asked the Plan to pay for the office visit. You say that you had a referral for the appointment. The Plan 
denied your request. The Plan says that the provider was not a network provider. 
 
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. We find that the Plan did not tell us whether the referring physician was in-
network or out-of-network, so we cannot determine whether the referral made was plan directed care. 
Therefore, we decided that the Plan has to pay for the office visit received on July 21, 2023, with an out-of-
network provider.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
August 11, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with 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 $100 
copayment for outpatient hospital services/basic radiological services. 
 
You have been asked to pay a $100 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/basic radiological 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 outpatient hospital services provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitored anesthesia care (procedure code 01992) rendered 
on March 31, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no documentation available to show that there was a condition or situation that 
required monitored anesthesia care. 
 
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 there is no documentation of extraordinary circumstances that support the need for monitored 
Anesthesia care in this case. Therefore, the service was not medically reasonable and 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 monitored anesthesia care (procedure code 01992) rendered on March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851) rendered on August 24, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be considered for maximum 
reimbursement. The Plan denied your request. The Plan says there is no documentation of recent injury, 
surgery, or instability to the knees. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the enrollee has not had recent surgery or a recent injury. The documentation 
doesnt support that the joint is unstable or that there is joint laxity. The requested knee orthosis is 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 a knee orthosis (L1851) rendered on August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. The enrollee does not have a qualifying diagnosis for a group 3 wheelchair. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis.  
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the requested CT scan.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found medical necessity of the requested CT scan 
of the abdomen and pelvis has not been established in the submitted records. The CT scan cannot be approved 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 30, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on July 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 23, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 24, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one bundled code. 
 
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 lab panel provided on April 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the photochemotherapy treatment provided 
on August 02, 2023, to August 21, 2023. 
 
You asked the Plan to reduce the copayment for the photochemotherapy treatment. You say that you are 
requesting the claims be reprocessed with a lower copayment amount. 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 outpatient hospital services.  
You have been asked to pay a $95 copayment for the photochemotherapy treatment. This item/service falls 
within the outpatient 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. Therefore, we decided that the Plan does not have to reduce the copayment for 
the photochemotherapy treatment provided on August 02, 2023, to August 21, 2023.