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

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided to the enrollee on 
March 2, 2021. 
 
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 payment for this service is always bundled into payment for other services not specified. 
 
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 99100 is "Anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)." 
 
 We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status 
indicator of "B" which means that it cannot be paid separately, and that payment for this code is always 
included in payment for other services. 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 anesthesia 
services (99100) provided to the enrollee on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
June 4, 2020, by an OON provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the claim was denied for no authorization. 
You called and then discovered that the Plan does not cover out of network providers. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) 
provided on June 4, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and lab services provided on June 20, 2021, 
by an OON provider. 
 
You asked the Plan to pay for the services provided. You say that the services were an emergency. The Plan 
denied your request. The Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 had network providers available 
who could have provided the services at issue in this appeal. There are insufficient medical records to show that 
the services were urgent or emergent. 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 office visit and lab services provided on June 20, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 82947, 84155, 84520, 85014, 
85018, 85049, 83735, 84132, 84295, 85025, 83036, 84466, 82565, 82607, 82728, 82746, 83540, 84439, 84443, 
85027, 80171, 85014, 85018, and 85049 provided on August 4, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 codes 82947, 84155, 84520, 85014, 85018, 85049, 83735, 84132, 84295, 85025, 83036, 
84466, 82565, 82607, 82728, 82746, 83540, 84439, 84443, 85027, 80171, 85014, 85018, and 85049 are not 
supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect 
the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting place of service 11. This 
means codes 82947, 84155, 84520, 85014, 85018, 85049, 83735, 84132, 84295, 85025, 83036, 84466, 82565, 
82607, 82728, 82746, 83540, 84439, 84443, 85027, and 80171 are not supported by the documentation. 
Codes 85014, 85018, 85049 are included in codes 85025 and 85027; therefore, cannot be separately 
reimbursed. 
 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82947, 
84155, 84520, 85014, 85018, 85049, 83735, 84132, 84295, 85025, 83036, 84466, 82565, 82607, 82728, 82746, 
83540, 84439, 84443, 85027, 80171, 85014, 85018, and 85049 provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 5, 2021 to 
April 8, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the day of discharge, death, or a day on which a 
patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of 
admission. 
  
We looked at the file and Medicare rules. The file shows that the enrollee was discharged from the hospital on 
April 8, 2021 for three days of service. The provider billed four days of service, which exceeds the days of 
service rendered. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services 
rendered from April 5, 2021 to April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hepatobiliary system imaging provided 
on May 24, 2021. 
 
You asked the Plan to waive the copayment for the hepatobiliary system imaging. You say that you dont have 
the money and the Plan should pay your copayment. The Plan denied your request. The Plan says the 
copayment applied 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 $195 
copayment for all other diagnostic and nuclear medicine radiological services.  You have been asked to pay a $195 copayment for the hepatobiliary system imaging. The hepatobiliary system 
imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 
The hepatobiliary system imaging is considered a nuclear medicine study. 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 hepatobiliary system imaging provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel rendered on July 15, 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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that more than 6 pathogens were tested. 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 respiratory panel rendered on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for ostomy supplies (A4430, 
A4432, A4405, A4407) provided on January 19, 2021. 
 
You asked the Plan to reimburse you an additional amount for the ostomy supplies. You say that you would 
like reconsideration because you were told that you would be reimbursed for this equipment. The Plan denied 
your request. The Plan says becuase the claim was a Direct Member Reimbursement (DMR), the Plan paid the 
Medicare allowable amount for each code. 
 
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.  
 
 You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the 
Durable Medical Equipment 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.  
 
Of note, the record indicates that these supplies were received out-of-network. The Plan is only responsible for 
paying the Medicare Allowed amount for these supplies. It is not the responsibility of the Plan to reimburse you 
any additional amount beyond the Medicare Allowed Amount. If you have been charged more than the 
Medicare Allowed Amount, please contact your regional Medicare office. Therefore, we decided that the Plan 
does not have to reimburse you an additional amount for ostomy supplies (A4430, A4432, A4405, A4407) 
provided on January 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 physical therapy visits. 
 
You asked the Plan to pre-approve 24 physical therapy visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 24 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollees condition beyond what was approved by the health plan. The 
enrollee has had prior therapy approved and the records do not demonstrate that the enrollee needs additional 
therapy with the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The should be able to transition to a home exercise program with the already approved therapy. The 
requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of 
a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 24 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this is not indicated for the enrollee. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertilfex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion services rendered on May 27, 2021. 
 
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. The file shows that home infusion therapy services 
were rendered. 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 services rendered 
on May 27, 2021.  
 
Benefits for these 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 20, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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. 
 
We find that the various denied codes are not supported in the medical record. Specifically, the place of service 
on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim 
reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a 
doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 7, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the thorax (71260) provided 
on April 7, 2021. 
 
You asked the Plan to waive the copayment for a CT scan of the thorax. You say that the scan at issue was 
inconclusive and necessitated a follow-up imaging procedure. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
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 $200 
copayment for advanced radiology services.  
 
 
 You have been asked to pay a $177.33 copayment for a CT scan of the thorax. A CT scan of the thorax falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay less than or equal to 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 CT scan of the thorax (71260) provided on April 7, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on November 16, 2020. 
 
You asked the Plan to pay for the testing services. You say that the panel is designed to provide clinical 
decision support. The Plan denied your request. The Plan says the billed services cannot be verified. 
 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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one 
unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Tempus gene panel provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the photodynamic therapy by external 
application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and 
illumination/activation of photosensitive drug(s), per day (96567) and the Aminolevulinic acid for topical 
administration (J7308) provided on June 10, 2021. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 
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 Medicare Part B prescription 
drugs. A separate physician office copayment may apply if other services are rendered at the time of the visit. 
Additionally, you must pay a $35 copayment per visit to a specialist.  
 
You have been asked to pay $113.60 which includes a $35 copayment for the specialist visit provided and  
the Plan allowed amount of $393 x 20% coinsurance=$78.60 for the Medicare Part B drug provided. 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 photodynamic therapy by external application of light to 
destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of 
photosensitive drug(s), per day (96567) and the Aminolevulinic acid for topical administration (J7308) 
provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on January 6, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this 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 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 (99214) provided on January 6, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the enrollee will not make a significant functional recovery in a reasonable and 
predicted period of time in an IRF. The enrollee does not need therapy at an IRF level with an interdisciplinary 
approach. While the enrollee may benefit from physical therapy or occupational therapy, the enrollee's rehab 
needs can be safely met when ready in an alternate and lower intensity setting such as a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.