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

 
We decided that the Plan does not have to pay for procedure code(s) 73070 billed for date of service November 
3, 2021. 
 You asked the Plan to pay for procedure code(s) 73070. You say that this service was medically necessary and 
appropriate. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 73070. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 73070. Based on this information, 
we decided that Medicare rules for coverage of procedure code 73070 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 73070 billed for date of service November 3, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 30, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device lead provided on August 14, 2022. 
 
You asked the Plan to pay for the TENS device lead. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the items billed are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the proof of delivery did not include an order number or details to corroborate the delivery ticket 
submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical 
nerve stimulation (TENS) device lead provided on August 14, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the blood glucose monitor replacement battery, test strips, calibrator 
solution/chips, and lancets provided from July 3, 2022, to September 20, 2022. 
 
You asked the Plan to pay for the blood glucose monitor replacement battery, test strips, calibrator 
solution/chips, and lancets. You say that you disagree with the Plan's denial. The Plan denied your request. The 
Plan says that the records do not support the service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied this claim due to "records do 
not support service". The documentation does not provide detail regarding why the items are not supported. 
The documentation also states that the Plan states they would have overturned their decision if they had 
processed it within the required timeframe. No other denial rationale was provided. The Plan did not 
substantiate their denial. Therefore, we decided that the Plan has to pay for the blood glucose monitor 
replacement battery, test strips, calibrator solution/chips, and lancets provided from July 3, 2022, to September 
20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0482 provided on September 14, 
2022. 
 
You asked the Plan to pay for the drug testing. 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 G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed.  
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation shows 
that seven drug classes were tested. This means the documentation does not support 15-21 drug classes were 
tested. 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 drug testing coded G0482 provided 
on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 03, 2022, to August 
31, 2022. 
 
You asked the Plan to pay for nursing facility care. 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 nursing facility care 
provided on August 03, 2022, to August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 01, 2022. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
November 01, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Aranesp is covered when specific criteria are 
met. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has lung cancer and anemia 
due to chemotherapy. The records do not support that other causes of anemia had been ruled out in this case. 
The criteria for coverage are not met and the Aranesp is not reasonable or medically necessary at this time. 
 
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 Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary-level referral for an office visit and testing 
with an ophthalmologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show a need for a tertiary level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you do not need the highly specialized level of care that a tertiary level referral would provide. You 
are noted to have stable glaucoma under control with glaucoma eye drops and at target intraocular 
pressure. The cataracts also did not require surgery, and the visual acuity is normal at 20/20 in both 
eyes. Therefore, you are able to see an in-network Provider that is available, and it was not medically necessary 
to be referred to a tertiary level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary-level referral for an office visit and testing with an ophthalmologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
October 13, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $250 
copayment for outpatient diagnostic tests/diagnostic procedure or test at a network outpatient facility.  
 
You have been asked to pay a $250 copayment for an outpatient diagnostic test. However, you are being asked 
to pay $223.69 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/diagnostic procedure or test at a network outpatient facility 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 outpatient diagnostic test provided on October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis, and the addition 
to lower extremity orthosis provided on August 30, 2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis, the knee orthosis, and the addition to lower extremity 
orthosis. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
items rendered are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Review of the file shows that the enrollee's 
claim history does not reflect any claims billed by the prescribing physician or the group practice. There is a 
proof of delivery showing shipping and delivery dates; however, there was no delivery confirmation provided 
for the items billed and no signed delivery ticket. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the lumbar-sacral orthosis, the knee orthosis, and the addition to lower extremity orthosis provided on 
August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an office visit provided from May 6, 2022 to 
August 5, 2022. 
 
You asked the Plan to reimburse you for the office visit. The Plan denied your request. The Plan says while you 
can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. 
Except for emergency care, we cannot pay a provider who has opted out of or been excluded or precluded from 
the Medicare Program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
an office visit provided from May 6, 2022 to August 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 19, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are requesting reconsideration. 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 
provided on September 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 06, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copaymet. 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 $225 
copayment for outpatient surgery/Medicare-covered ambulatory surgical center visit. 
 
You have been asked to pay a $225 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered ambulatory surgical center visit 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 outpatient surgery provided on May 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the comprehensive oral evaluation 
(D0150), prophylaxis - adult  (D1110), bitewings - four radiographic images (D0274), provided on September 
7, 2022, and resin-based composite - two surfaces, anterior (D2331) provided on September 29, 2022. We also 
decided the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2220), and 
intraoral  periapical- each additional (D2330) provided on September 7, 2022. 
 
You asked the Plan to waive the coinsurance for codes D0150, D1110, D0274, and D2331 and pay for codes 
D0220 and D0230. You say that you specifically asked the Plan for a dentist that was in-network. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. The Plan also says that the dental 
services represented by dental codes D0220 and D0230 are covered but limited to one set of bitewing x-rays 
(up to four views) every 2 years or up to six periapical films every 2 years (not both). 
 
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 50% 
coinsurance of the approved amount for covered services provided by an out-of-network dentist plus any 
difference between the approved and charged amount. Medicare generally does not cover dental services. 
However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage 
rules apply in this case. 
 
You have been asked to pay at 50% coinsurance for codes D0150, D1110, D0274, and D2331. This service 
falls within the dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the resin-based composite - two surfaces, anterior (D2220), and intraoral  periapical- 
each additional (D2330) was exhausted on September 7, 2022. Therefore, we decided that the Plan does not 
have to pay for codes D2220 and D2330.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes G0471, P9603, 80048, 
83735, and 83880 provided on August 22, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes G0471, P9603, 80048, 83735, and 83880. 
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 laboratory services 
billed under codes G0471, P9603, 80048, 83735, and 83880 provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 15, 2022. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
August 15, 2022.
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 June 
23, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copaymet. 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 $35 
copayment for Personal Choice 65 Prime Rx PPO/physician/practitioner services/specialist. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
Personal Choice 65 Prime Rx PPO/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 June 23, 2022.