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

 
We decided that the Plan does not have to pay for the Guidance UTI (urinary tract infection) test billed with 
multiple procedure codes for date of service April 27, 2022. 
 
You asked the Plan to pay for the Guidance UTI test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules have not 
been met in this case. Specifically, the records show that a single panel was ordered and performed on a single 
specimen, but this service was billed by reporting individual components with multiple procedure codes. Therefore, we decided that the Plan does not have to pay for the Guidance UTI (urinary tract infection) test 
billed with multiple procedure codes for date of service April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the power wheelchair rendered on April 
26, 2021. 
 
You asked the Plan to waive the coinsurance for these services. You say that you did not receive a wheelchair. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for in-network durable medical equipment.  
 
Review of the file shows that you received a power wheelchair on April 26, 2021. The file contains a delivery 
form confirming that the power wheelchair was delivered and signed for on April 26, 2021. You have been 
asked to pay a 10% coinsurance for these services. This item/service falls within the in-network 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. Therefore, we decided that the Plan does not have to waive the coinsurance for the power 
wheelchair rendered on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement for payment with the dialysis facility. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology (labs) provided on March 21, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for molecular pathology (labs). You say that this should be covered. The Plan denied 
your request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 molecular pathology (labs) provided on March 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam provided on January 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that prior authorization was not required when 
the service is performed in an ambulatory surgical facility or office. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
 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 did not pre-approve the 
medical eye exam. We found no exception that would require the Plan to pay for the medical eye exam. 
Therefore, we decided that the Plan does not have to pay for the medical eye exam provided on January 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care visit provided on March 15, 2022, to March 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health care visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  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 home health care visit provided on March 15, 
2022, to March 18, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) Acupuncture, each 
additional 15 minutes (97811) and infrared light therapy (97026) provided November 24, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that this documentation supports the medical 
necessity services provided to the enrollee. Please reconsider the previously denied claim, based on the additional information. The Plan denied your request. The Plan says this service does not meet the coverage 
requirements in the applicable Local Coverage Determination or National Coverage Determination. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture treatment was provided for neck 
pain. Infrared therapy services are not covered. Also, the services were rendered by a licensed acupuncturist. 
Currently, acupuncturists are not recognized by CMS as Medicare providers, and are not eligible to bill for 
acupuncture services. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 
minutes (97810) Acupuncture, each additional 15 minutes (97811) and infrared light therapy (97026) provided 
November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and bladder testing provided on June 13, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and bladder testing. You say that the services were medically 
necessary. The Plan denied your request. The Plan says a valid referral/authorization was not obtained prior to 
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 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 and bladder testing provided on 
June 13, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97026) provided on May 4, 2022. 
 
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 are not payable as they were 
rendered by an in-eligible provider type. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were rendered 
by an acupuncturist who was not under the supervision of a physician, physicians assistant, nurse practitioner, 
or clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture 
treatment (97810, 97811) and the infrared therapy (97026) provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician pathology services provided on June 30, 2021, 
billed with code 88360. 
 
You asked the Plan to pay for the physician pathology services. You say that because the sample is stored 
before being sent to the laboratory, this is not a hospital service, and the TC is payable. The Plan denied your 
request. The Plan says the TC is not payable in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that independent laboratories cannot be paid for the 
TC of a physician pathology services rendered to a hospital outpatient.  
 
We looked at the file and Medicare rules. The documentation shows that this testing was performed for a 
hospital outpatient. Only the professional component is payable in this case. Based on this information, we decided that Medicare rules for coverage of the physician pathology services have not been met. Therefore, we 
decided that the Plan does not have to pay for the physician pathology services provided on June 30, 2021, 
billed with code 88360.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on January 05, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the 
enrollee approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 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 outpatient services provided on January 05, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service July 27, 
2022. 
 You asked the Plan to pay for procedure code 76942. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 76942 is bundled into 
payment for code 76937. 
 
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 76942 
is a column II code to column I code 76937. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76942 billed for date of service July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99217 billed for date of service June 15, 2022. 
 
You asked the Plan to pay for code 99217. You say that the medical records support payment of this claim. The 
Plan denied your request. The Plan says code 99217 was not billed with the required initial or subsequent 
observation care code. 
 The Plan must follow Medicare rules. Medicare rules say that when billing for observation services provided 
on the day of discharge (code 99217), providers must also bill with an appropriate code for the preceding days 
of observation services.  If only one day of observation services are provided, a different code (i.e., not 99217) 
should be billed.  In this case, you billed only code 99217 with no codes billed for preceding days of 
observation services. This code should not be billed without these preceding day codes, rather, a different code 
should be used if only one day of service is rendered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99217 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99217 billed for date of service June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided June 23, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting a fast appeal for the claim due to 
the medical MRI enclosed. The Plan denied your request. The Plan says this service is not covered when 
rendered by a chiropractor. 
 
The Plan must follow Medicare rules. 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. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) provided June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing provided on July 13, 2021. 
 
You asked the Plan to pay for infectious-agent testing. You say that the claim was delayed due to incorrect 
insurance information from the referring physician's office. The Plan denied your request. The Plan says rules 
for payment have not been met. 
 
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 infectious-agent testing was not filed until July 20, 2022. 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 infectious-agent testing provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive thier care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility for payment. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97026) provided on November 17, 2021. 
 
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 are not payable as they were 
rendered by an ineligible provider type. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were rendered 
by an acupuncturist who was not under the supervision of a physician, physicians assistant, nurse practitioner, 
or clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture 
treatment (97810, 97811) and the infrared therapy (97026) provided on November 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 13, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date of service. 
 
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 ambulance services provided on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 29, 2022.