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 on August 3, 2023 to August 
7, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies (HHA's) must submit 
home healh (HH) claims with the 4th digit of 9. 
 
We looked at the file and Medicare rules. The claim was billed with type of bill 0323. The fourth digit must be 
9. 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 on 
August 3, 2023 to August 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies coded as A6199, A6212, A6196, 
A6252, A6446, A4450 and A6455 provided on July 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that please review the attached documents 
which shows the medical necessity for these supplies. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 
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 wound care supplies coded as A6199, A6212, 
A6196, A6252, A6446, A4450 and A6455 provided on July 13, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
14, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were not treated 
appropriately for your injuries in the ambulance or the hospital. 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 ambulance services. 
 
You have been asked to pay a $260 copayment for the ambulance services. 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 copayment for the ambulance 
services provided on July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 9, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58726, this type of testing must be billed with a single unit of service of a single 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 August 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 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 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 July 24, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy visits (90837) provided on 
April 18, 2023, to May 30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the psychotherapy visit. You say that you ask for review of the documents and 
reconsideration of this claim for reimbursement. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 
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 individual psychotherapy visits (90837) 
provided on April 18, 2023, to May 30, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87491 and 87640) 
rendered on August 14, 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 records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules also say that a physician order must be present for labs to be covered. 
 
We find that CPT codes 87491 and 87640 are not supported in the medical record. Specifically, there is no 
order for these lab codes. 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 laboratory services 
(procedure code 87491 and 87640) rendered on August 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11730 billed for date of service July 10, 
2023.  
 You asked the Plan to pay for procedure code 11730. You say that this should be paid for. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11730 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 11730 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11730 billed for date of service July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service July 11, 
2023.   
You asked the Plan to pay for procedure code 88374. 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 88374 is 5. The MAI value for this code is 3. You billed 8 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 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service July 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a gastrointestinal (GI) procedure provided 
on June 26, 2023. 
 
You asked the Plan to waive the copayment for a gastrointestinal (GI) procedure. You say that you cannot 
afford all these hospital bills and need help. 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 $350 
copayment for outpatient surgery, including services provided hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for a gastrointestinal (GI) procedure. This item/service falls 
within the outpatient surgery, including services provided hospital outpatient facilities and ambulatory surgical 
centers 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 gastrointestinal (GI) procedure 
provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 1, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 the laboratory services provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 31, 2023, billed with 
procedure code 93971. 
 
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 the requested medical records have not been 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, no medical records for the date of service in question have been provided for review. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on March 31, 2023, 
billed with procedure code 93971.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient procedure with magnetic 
resonance technology (MRT) provided on July 28, 2023. 
 
You asked the Plan to waive the copayment for an outpatient procedure with magnetic resonance technology 
(MRT). You say that you do not believe you owe this 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 $295 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $295 copayment for an outpatient procedure with magnetic resonance 
technology (MRT). This item/service falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 outpatient procedure with magnetic resonance technology (MRT) provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92014) closure of lacrimal 
punctum (68761) and scanning computerized ophthalmic diagnostic imaging (92133) provided on August 10, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ophthalmology services. You say that please reconsider reimbursement. The 
doctor is credentialed and in network with Medicare, Medicaid and commercial United Healthcare plans. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 
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 ophthalmological services (92014) closure of 
lacrimal punctum (68761) and scanning computerized ophthalmic diagnostic imaging (92133) provided on 
August 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 procedure code 99497 billed for date of service June 15, 
2023. 
 You asked the Plan to pay for procedure code 99497. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99497 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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 99497 billed for date of service June 15, 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 from 
January 23, 2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you thought this 
service would be fully covered. 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 $240 
copayment per day, for days one to eight of the inpatient hospital stay. You have been asked to pay $1,722.95, which is less than the standard copayment for the inpatient hospital stay 
due to meeting your MOOP amount during this service. This 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 January 23, 2023, to January 31, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a nerve injection provided on May 18, 2023. 
 
You asked the Plan to pay for nerve injection. You say that you should not be left responsible for payment of 
this bill. The Plan denied your request. The Plan says that this code was billed with modifier -GY which means 
it is not covered and you are responsible for the charge. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
This service was performed by a contract provider. The file does not show that the Plan provided notice that 
nerve injection would not be covered. No documentation was submitted to support the validity of modifier -GY 
applied to this procedure. Under Medicare rules, this means nerve injection is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for a nerve injection provided on May 18, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 7, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to 
independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee was inpatient for this date 
of service. This claim is not separately payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not 
have to pay for the ambulance services provided on July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 6, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The testing provided in this case is not covered under DEX 
Diagnostic Exchange. Based on this information, we decided that Medicare rules for coverage of the testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 13, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on July 13, 2023, by an out-of-network 
(OON) provider.