Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for code 99285 billed for date of service September 25, 2022. 
 
You asked the Plan to pay for code 99285. You say that this claim was billed correctly. The Plan denied your 
request. The Plan says that code 99285 is not supported by the medical record. The enrollee's presenting 
problem was not a high severity and there was no immediate or significant threat for life or physiological 
function. As a result, this claim was down-coded to code 99284. 
 
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 99285 is Emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or 
mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. 
 
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 code 99285. Our reviewer says that code 99285 was 
supported by the medical record. Our reviewer found the enrollee was seen in the emergency department for a 
fall and inability to care for themselves and needing placement. A computed tomography scan of the head was 
negative. However, the enrollee was found to be anemic, and packed red blood cells had to be provided. This 
was a high complexity medical case, so the billing of 99285 was 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 code 99285 have been met. Therefore, we decided that the Plan has to pay for 
code 99285 billed for date of service September 25, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for  an outpatient diagnostic test provided on 
June 20, 2023. 
 
You asked the Plan to waive the cost share for  an outpatient diagnostic test. You say that you disagree with the 
cost share. 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. Your 
contract with the Plan says that there is a $400 deductible and a 2% coinsurance which applies to outpatient 
diagnostic tests.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests 
benefit category. You are being asked to pay $50.96 towards your $400 deductible. You are also being asked to 
pay $110.52 towards your coinsurance. The total amount you are being asked to pay is $161.48 ($50.96 + 
$110.52 = $161.48). The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$400 deductible and a 2% coinsurance which applies to outpatient diagnostic tests. This cost sharing is a 
contractual obligation that had not been met at the time an outpatient diagnostic tests was received on June 20, 2023. Therefore, we decided that the Plan does not have to waive the cost share for  an outpatient diagnostic 
test provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation and management 
provided on May 12, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation and management. 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 a home or residence visit 
for the evaluation and management provided on May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a clinic visit and the laboratory services provided on June 05, 
2023. 
 
You asked the Plan to pay for a clinic visit and 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 a clinic visit and the 
laboratory services provided on June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on May 1, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that your first shot was done at a pharmacy. You 
say that your provider advised you needed it as soon as possible. You also say that this was denied. The Plan 
denied your request. The Plan says the services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and 
administration (90471) provided on May 1, 2023.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vitrectomy provided on June 12, 2023. 
 
You asked the Plan to pay for vitrectomy. You say that this service is supported in the records. 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 vitrectomy provided on 
June 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external electrocardiographic provided on April 28, 2023. 
 
You asked the Plan to pay for external electrocardiographic. 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 external 
electrocardiographic provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous infusions and the portable pump maintenance 
provided on June 19, 2023.  
You asked the Plan to pay for the intravenous infusions and the portable pump maintenance. 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 intravenous 
infusions and the portable pump maintenance provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99233) provided on March 9, 2023 to March 
23, 2023. 
 
You asked the Plan to pay for the hospital care. You say that this service was 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation 
care, which requires a medically appropriate history and/or examination and high level of medical decision 
making or must reach 50 minutes of total time. 
 
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 hospital care. Our reviewer says that this service is not 
supported by the records. Our reviewer found the documentation did not support a high level of medical 
decision making or more than 50 minutes spent on this service. 
 
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 hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care (99233) provided on March 9, 2023 to March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement procedure provided on April 18, 2023. 
 
You asked the Plan to pay for a 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 debridement procedure 
provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing provided on July 13, 2023. 
 
You asked the Plan to waive the copayment for lab testing. You say that you say that you didnt know that 
there would be a cost for the services. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab testing. 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. However, since the allowed amount is less than the standard 
copayment, you only owe $9.71. Therefore, we decided that the Plan does not have to waive the copayment for 
lab testing provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator, the portable 
oxygen system, a wheelchair, and the leg rests provided on July 31, 2023. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator, the portable oxygen system, a 
wheelchair, and the leg rests. You say that you cannot afford the cost share. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the oxygen concentrator, the portable oxygen system, a 
wheelchair, and the leg rests. This item/service falls within the durable medical equipment 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. The 
total amount you owe is $30.41 ($152.06 allowed amount x 20% = $30.41). Therefore, we decided that the 
Plan does not have to waive the coinsurance for the oxygen concentrator, the portable oxygen system, a 
wheelchair, and the leg rests provided on July 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on June 29, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 home visit evaluation 
provided on June 29, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
February 16, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that medical records support code 76706-26 and the 
claim should be paid. The Plan denied your request. The Plan says that the documentation received do not 
indicate that the patient received the screening study for one of the Centers for Medicare and Medicaid Services 
risk categories of a family history of abdominal aortic aneurysm, a man aged 65 to 75 who has smoked at least 
100 cigarettes in his lifetime, or other risk factors recommended by the United States Preventive Services Task 
Force. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for AAA for beneficiaries who meet certain criteria and fall into at least one of three risk categories. 
 
In this case, the CPT Code Manual definition of code 76706-26 is the ultrasound of the abdominal aorta. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the AAA screening have not been met. Specifically, the medical records and diagnosis code 
submitted on this claim do not support that the enrollee has a family history of AAA, is a man aged 65 to 75 
who has smoked at least 100 cigarettes in his lifetime or is an enrollee who manifests other risk factors in a 
beneficiary category recommended for screening by the United States Preventive Services Task Force 
regarding AAA. Based on this information, we decided that Medicare rules for coverage of the ultrasound have 
not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound of the abdominal 
aorta (76706) provided on February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on March 6, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on March 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 19, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee should not be 
responsible for 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 $235 
copayment for each in and out-of-network one-way Medicare-covered ground ambulance trip. 
 
You have been asked to pay a $235 copayment for ambulance services. This item/service falls within the each in and out-of-network one-way Medicare-covered ground ambulance trip 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 ambulance services provided on March 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023 to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023 to July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on July 
12, 2023. 
 
You asked the Plan to pay for initial hospital inpatient or observation care. You say that the services rendered 
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 initial hospital inpatient 
or observation care provided on July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
February 24, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. 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 $300 
copayment for the ambulance transportation. 
 
You have been asked to pay a $300 copayment for the ambulance transportation. This item/service falls within 
the the ambulance transportation 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 transportation provided on February 24, 2023.