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

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on May 13, 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 Current Procedural Terminology (CPT) code 99284-25 remains not supported. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 99284 is not supported in 
the records, as the records do not demonstrate a moderate level of medical decision making. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99284) rendered on May 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 13, 2021. 
 
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 the claim was filed untimely. 
 
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 lab services was not filed until June 2, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for lab services provided on March 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oblique lumbar interbody fusion at L3-L5. 
 
You asked the Plan to pre-approve an oblique lumbar interbody fusion. You say that the surgery would allow 
them to properly decompress the enrollee's nerves and provide stability to their spine in order to improve their 
quality of life. The Plan denied your request. The Plan says the medical records indicate that the enrollee 
participated in less than 3 months of physical therapy. 
 
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 an oblique lumbar interbody fusion. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there are not enough conservative measures to include 3 months of 
physical therapy for back pain. More conservative measures are needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oblique lumbar interbody fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an oblique lumbar interbody fusion at L3-L5.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641, and 87500 billed for June 12, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not 
supported. 
 
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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not supported in the 
medical record. Specifically, the records show that a panel of tests was performed and there is a more 
appropriate singular code for these services. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 billed for June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing services provided on May 22, 
2023. 
 
You asked the Plan to waive the copayment for hearing 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 $45 
copayment for hearing services. 
 
You have been asked to pay a $45 copayment for hearing services. This item/service falls within the hearing 
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 hearing services provided 
on May 22, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 31, 2023, to 
April 5, 2023. You asked the Plan to pay for the inpatient hospital care. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the initial date of service at issue on this appealed 
claim. The record shows the providers claim included the date of service March 31, 2023, which was part of 
the Hospice month. The claim also included the dates of service April 1, 2023, through April 5, 2023, which 
were not part of the Hospice month. Therefore, we decided that the Plan does not have to pay for hospice care 
provided from March 31, 2023, to April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 29, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that services were provided when the enrollee 
was residing in a skilled nursing facility, and were provided on an on-call basis. The Plan denied your request. 
The Plan says the services were not authorized. 
 The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the nursing facility care provided on June 29, 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, 
avulsion of nail plate and debridement of nail provided on May 18, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation and management, avulsion of nail 
plate and debridement of nail. 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, avulsion of nail plate and debridement of nail provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management provided on February 07, 2023, to March 
27, 2023. 
 
You asked the Plan to pay for pain management. You say that you are appealing the claim payment denial. 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 pain management 
provided on February 07, 2023, to March 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
May 20, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. 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 $350 
copayment for outpatient diagnostic tests/Medicare-covereddiagnostic radiologyservices. 
 
You have been asked to pay a $350 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/Medicare-covereddiagnostic radiologyservices 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 $252.85 Therefore, we decided that the Plan does not have to 
waive the copayment for an outpatient diagnostic tests provided on May 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
31, 2023, to March 03, 2023. 
 
You asked the Plan to waive the copayment for ambulance 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 $240 
copayment for ambulance services. 
 
You have been asked to pay a $240 copayment for 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. The total you owe is $480 ($240 copayment x 2 rides = $480). Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance services provided on January 31, 2023, to March 03, 
2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (97112, 97140, 97110) provided on April 
24, 2023. 
 
You asked the Plan to pay for physical therapy (97112, 97140, 97110). You say that you are appealing the 
claim payment denial. 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 physical therapy (97112, 
97140, 97110) provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
24, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 05, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that we are an independent lab and should not have to 
be approved or denied. 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 testing 
provided on June 05, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from December 6, 2022, to December 10, 2022. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you are on a 
fixed income and cannot afford this large 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 $325 
copayment per day, for days 1-5 for inpatient hospital services.  
 
You were in the hospital for 4 days, resulting in a $1,300 total copayment (4 x $325 = $1,300). 
 You have been asked to pay a total $1,300 copayment for an in-network acute inpatient stay. This item/service 
falls within the inpatient hospital services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an in-network acute inpatient stay provided from December 6, 2022, to December 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genomic profiling test provided on May 17, 2023. 
 
You asked the Plan to pay for a genomic profiling test. You say that this test was 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 genomic profiling test 
provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2023, by an OON 
provider.  
 
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 the service was 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 an office visit provided on January 13, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99223, 99233, and 99239 for date of service February 
4, 2023, to February 6, 2023. 
 
You asked the Plan to pay for codes 99223, 99233, and 99239. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 The CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation care, per day, 
for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 50 minutes must be met or exceeded. 
 
The CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
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 codes 99223, 99233, and 99239. Our reviewer says that the 
documentation does not support the codes billed. Our reviewer found the enrollee has a history of chronic back 
pain and was admitted for elective lumbar spine surgery. The documentation does not support a high level of 
medicine making during the dates provided. This means codes 99223 and 99233 are not supported. The 
documentation does not support duration of time greater than 30 minutes; therefore, code 99239 is not 
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 codes 99223, 99233, and 99239 have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 99223, 99233, and 99239 for date of service February 4, 2023, to 
February 6, 2023.