Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the 
out of network (OON) provider on February 20, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on 
February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the specialist services provided on February 20, 
2020. 
 
You asked the Plan to waive the copay for the specialist services. You say that you did not have a copay last 
year for the service. The Plan denied your request. The Plan says the claim was processed 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 
copay per visit to a specialist for physician services.  
 
You have been asked to pay a $20 copay for the specialist services. The services fall within the physician 
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 copay for the specialist services provided 
on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided from March 16, 2020 to April 20, 2020.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that you believe you only received covered services. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Although the Plan offers a chiropractic benefit that exceeds Medicare coverage, this benefits excludes extraspinal manipulation. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided from March 16, 2020 to April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on June 22, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 the drug testing rendered on June 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for PT/INR testing billed for February 17, 2020.
You asked the Plan to pay for the PT/INR testing. You say that you would like reconsideration because this code has no frequency limitation. The Plan denied your request. The Plan says this code encompasses four tests so billing for four tests weekly exceeds what is covered by Medicare
The Plan must follow Medicare rules. Medicare rules say that testing with the home PT/INR system should not be done more than once per week. In this case, the definition of the code G0249 is Provision of test materials and equipment for home inr monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests. As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare. Evidence was submitted showing that payment for this code was made on February 14, 2020. Payment of this code weekly would indicate testing four times per week, which is not covered under Medicare guidelines. Therefore, we decided that the Plan does not have to pay for PT/INR testing billed for February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 
1, 2019. 
 
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom 
profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order 
or medical records stating exactly what tests are to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the testing at issue is not supported in the medical record. There is no evidence that shows the test 
was individualized to identify specific non-prescribed medications or illicit substances. The records provided 
do not document concerns based on clinical review and judgement. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the presumptive and definitive drug testing provided on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and the chronic care management services (99490) rendered by the out of network (OON) provider on November 25, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 domiciliary or rest home visit (99336) and the chronic care management services (99490) rendered by the out of network (OON) provider on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 24, 2020. 
 
You asked the Plan to pay for the wound care supplies. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for 
inpatient services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other 
than the facility or hospital for services furnished to an enrollee.  
 
Records show that the wound care supplies were used in a SNF. The facility must furnish all necessary covered 
supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies 
would have been included in the global payment submitted to the plan by the facility. If the health plan is not 
covering the SNF stay, the cost of these supplies is absorbed by the facility. Therefore, we decided that the Plan 
does not have to pay for the wound care supplies provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic small intestine follow-through study (74248) 
provided on March 15, 2020. 
 
You asked the Plan to pay for the radiologic small intestine follow-through study. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 74248 
cannot be billed as a stand-alone code. 
 
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 the 
radiologic small intestine follow-through study is an add-on code and has not been billed with the required 
primary procedure code. This code cannot be paid as a separate line item. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiologic small intestine follow-through study (74248) provided on March 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on June 3, 2019 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 has network providers 
available who can provide 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 lab work provided on June 3, 2019 by an out of 
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation (CPT Code 76376) provided to the enrollee on March 14, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The use of 3D-rendering with 
interpretation and reporting of computed tomography, magnetic resonance imaging, or other tomographic 
modality with image post-processing is not covered separately by Medicare if it is contained in the authorized 
radiologic procedure. Radiologic techniques using 3D-rendering will be considered integral to the radiology 
services and not a separate service. Reimbursement will be based on the payment for the primary radiologic 
imaging service. 3D rendering with interpretation and reporting of computed tomography, magnetic resonance 
imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; 
requiring image post-processing on an independent workstation may be considered medically unnecessary and 
denied if equivalent information obtained from the test has already been provided by another procedure 
(magnetic resonance imaging, ultrasound, angiography, etc.) or could be provided by a standard CT scan (two-
dimensional) without reconstruction. As a non-covered service it is not a benefit when ordered by either a 
contracted or a non-contracted provider.? Therefore, we decided that the Plan does not have to pay for 3D 
rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, 
or other tomographic modality with image postprocessing under concurrent supervision; not requiring image 
postprocessing on an independent workstation (CPT Code 76376) provided to the enrollee on March 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90792) provided on 
December 19, 2019. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. 
There were network providers available. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health services (90792) provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 17, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 the drug testing rendered on April 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a DXA bone density scan provided on January 13, 2020. 
 
You asked the Plan to pay for the DXA bone density scan. You say that you've changed the diagnosis code 
billed and that the claim should be reprocessed for payment. The Plan denied your request. The Plan says they 
are unable to determine medical necessity with the information provided. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also 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. We found that, despite requests from the Plan, the provider did not 
submit medical records to show why the DXA bone density scan was ordered or supporting its medical 
necessity. Based on this information, we decided that Medicare rules for coverage of the DXA bone density 
scan have not been met. Therefore, we decided that the Plan does not have to pay for a DXA bone density scan 
provided on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a visual field examination provided on 
March 10, 2020. 
 
You asked the Plan to waive the coinsurance for diagnostic test. You say that you believe this appointment was 
cancelled, so you should not be billed this amount. The Plan denied your request. The Plan says the 
coinsurance amount you are being charged is correct. 
 
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 10% 
coinsurance for diagnostic eye test. The allowed amount of the claim is $111.61, resulting in a coinsurance 
obligation of $11.16. 
 
You have been asked to pay 10% coinsurance for diagnostic test. Diagnostic test falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for a visual field examination provided on March 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total metabolic panel, CBC, and collection of venous 
blood provided on November 25, 2019. 
 
You asked the Plan to pay for the total metabolic panel, CBC, and collection of venous blood. You say that 
hospice would not cover this date of service. The Plan denied your request. The Plan says Original Medicare 
would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's 
terminal condition. 
 
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the total metabolic panel, CBC, and collection of venous 
blood provided on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 5, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not 
provided by the rendering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records from 
the billing provider for the date of service in question. Without these records, it cannot be determined that 
Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on March 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on January 3, 2020. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee x-ray (73650) provided on March 26, 2020. 
 
You asked the Plan to pay for the knee x-ray. You say that you would like reconsideration because you were 
not given correct information by the provider. The Plan denied your request. The Plan says this service was not 
reported with the required anatomical modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73650 is not supported in the record. Specifically, CPT code 73650 requires an 
anatomical modifier to indicate that the procedure was performed on one side of the body. Based on this 
information, we decided that Medicare rules for coverage of the knee x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the knee x-ray (73650) provided on March 26, 2020.  
 
Your complaint about being given incorrect information by the provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.