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

 
We decided that the Plan does not have to pay for medical services provided on March 1, 2022. 
 
You asked the Plan to pay for the medical services. You say that you submitted an Explanation of Benefits 
(EOB) showing that you timely filed your claim. The Plan denied your request. The Plan says you did not file 
your claim timely with the Plan. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until May 21, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Please note that the EOB 
you submitted with your appeal request does not show that this claim was submitted to the Plan. Rather, the 
document you submitted is actually a Summary of Benefits that states that the payer is the medical center, not 
the Plan in this case. As a result, this is not evidence of timely claim submission to the Plan. Therefore, we 
decided that the Plan does not have to pay for medical services provided on March 1, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the PrismRA testing (81479) provided on April 10, 2023. 
 
You asked the Plan to pay for the PrismRA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that this test is not covered in the DEX Diagnostics Exchange Registry. 
 
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 DEX Diagnostics Exchange Registry shows that the PrismRA 
test is covered. Thus, the Plans denial rationale is not supported. Therefore, we decided that the Plan has to 
pay for the PrismRA testing (81479) provided on April 10, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the skilled nursing facility (SNF) stay 
provided on May 23, 2023, to June 28, 2023. 
 
You asked the Plan to reduce the copayment for the skilled nursing facility (SNF) stay. You say that you would 
like the copayment reduced to a lower 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 $196 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $196 copayment for the skilled nursing facility (SNF) stay. This item/service falls within the skilled nursing facility (SNF) 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. The total you owe is $2,940 ($196 copayment x 15 days = 
$2,940). Therefore, we decided that the Plan does not have to reduce the copayment for the skilled nursing 
facility (SNF) stay provided on May 23, 2023, to June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided from 
February 11, 2023, to April 20, 2023. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that your wife was moved from floor 
to floor, she never left 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 $395 
copayment per admission, per as medically necessary, for inpatient hospital services, and a $250 copayment for 
outpatient hospital observation. You can find this information on pages 80 to 81, and 86 to 87 of the Plan's 
2023 Evidence of Coverage (EOC). You have been asked to pay a $1,830 total copayment for an inpatient stay ($395 + $395 + $250 + $395 + $395 
+ $395 = $1,830 total). This item/service falls within the outpatient hospital observation and 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. Therefore, we decided that the Plan does not have to waive the copayment for an acute inpatient stay 
provided from February 11, 2023, to April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (58571) provided on May 1, 2023. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (58571) provided 
on May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 18, 2020, to 
August 21, 2020. 
 
You asked the Plan to pay for the inpatient hospital services provided. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says the requested documentation has 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 inpatient hospital services provided 
have been met. Specifically, despite multiple requests from the Plan, the complete medical records for the dates 
of service in question have not been provided for review. Therefore, we decided that the Plan does not have to 
pay for inpatient hospital services provided on August 18, 2020, to August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the walker, folding, wheeled, adjustable or fixed 
height (E0143) provided August 3, 2023. 
 
You asked the Plan to reimburse you for a walker. You say that you purchased the rollator out of network, but 
you had no other choice. You are requesting reimbursement of your rollator purchased out of network. The 
Plan denied your request. The Plan says the walker was purchased from a supplier who does not participate 
with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the walker, folding, wheeled, 
adjustable or fixed height (E0143) provided August 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 31, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that you would like the Plan to reconsider their 
denial of payment. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B and an office visit on April 18, 
2023.  
 
You asked the Plan to waive the cost share for the Part B and an office visit. You say that you were under the 
impression that you were not going to owe anything. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered Part B drug. You must pay a $45 copayment per visit for a specialist 
office visit. The provider billed in the amount of $864 and the allowed amount is $469.92. For the service it's 
$469.92 x 20% = $93.98. For both services it's $93.98 + $45 = $138.98. Therefore, results in the total cost 
sharing amount of $138.98. 
 
You have been asked to pay a 20% coinsurance for the Part B and a $45 copayment for an office visit. This 
item/service falls within the Medicare Part B prescription drugs and physician/practitioner services, including 
doctors office visits benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the Part B and an 
office visit on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 02, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you shouldnt owe anything 
because you have cancer and they had to do another mammogram to confirm. 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 an ultrasound. 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 waive the copayment for an ultrasound 
provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 28, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5226) 
 
You asked the Plan to pre-approve the dental services. You say that you are homeless. You also say you took 
your teeth out one night to clean them, and you believe someone picked them up as you showered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture (D5226)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided 
on September 28, 2023, and billed with codes 87500, 87641, 87798, G0452, 87471, 87481, 87551, 87651, and 
87653. 
 
You asked the Plan to pay for the wound PCR panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says per Local Coverage Article (LCA) A58726, this type of testing must 
be billed as a single unit of service with 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 wound polymerase chain reaction (PCR) panel provided on September 28, 
2023, and billed with codes 87500, 87641, 87798, G0452, 87471, 87481, 87551, 87651, and 87653.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 1, 2023, to July 31, 
2023, billed with procedure code 90999. 
 
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 claim has not been reported with the required 
D5 value code. 
 
The Plan must follow Medicare rules. Medicare rules say that a Value code D5 is the result of the last Kt/V 
reading. This code is effective and required on all ESRD claims.   
We looked at the file and Medicare rules. We have verified that the claim has not been billed with the required 
D5 value code. 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 July 1, 2023, to July 31, 2023, billed with procedure code 90999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the Intracept basivertebral nerve ablation. You say that the enrollee's 
primary condition is chronic low back pain due to degenerative disc disease that has resulted in the 
development of vertebrogenic pain identified by degenerative endplates changes frequently known by the 
eponym modic on their magnetic resonance imaging (MRI). The Plan denied your request. The Plan says the 
Intracept basivertebral nerve ablation is not medically necessary. 
 
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 pre-approve the Intracept basivertebral nerve 
ablation. Our reviewer says that the Intracept basivertebral nerve ablation is not medically necessary. Our 
physician reviewer found that there is no MRI showing only modic changes without facet degenerative joint 
disease or stenosis. Also, the cause of pain is not clear, and the coverage criteria has not been met. 
 
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 Intracept basivertebral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99483) provided on May 16, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that F03.A3 has an Excludes1 note in relation to G30.8. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the physician services have not been met. Therefore, we decided that the Plan does not have to 
pay for physician services (99483) provided on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 26, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says multiple unbundled codes were billed for a single panel. 
 
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 lab services provided on June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that the Dexcom G7 sensor is a medical 
necessity. The Plan denied your request. The Plan says no medical reason was provided regarding why you 
can't continue to use the Freestyle Libre system. 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand for a 
CGM receiver. Based on this information, we decided that Medicare rules for coverage of the Dexcom G7 sensor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 sensor.