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

 
We decided that the Plan does not have to pay for wound debridement services provided on December 2, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound debridement services. You say that medically necessary services were 
rendered to the member as ordered by a credentialed physician. You also say that you were not informed 
authorization was required for billed procedure. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider and there is no referring provider involved in these services. The Plan 
also says they did not authorize any services for this provider or for the facility. 
 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 wound debridement services provided on 
December 2, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory Services provided on December 3, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory Services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Laboratory Services provided on December 3, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81284) provided July 7, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. The genetic panel was billed with multiple unbundled codes. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81284) provided July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Platelet Rich Plasma (CPT 0132T) provided from 
August 27, 2021, through September 10, 2021. 
 
You asked the Plan to pay for Platelet Rich Plasma. The Plan denied your request. The Plan says that Platelet 
Rich Plasma is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules 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. Based on this information, we decided that there is insufficient 
information in the case file to determine if Medicare rules for coverage of Platelet Rich Plasma have been met. 
Specifically, no medical records were provided for review. Therefore, we decided that the Plan does not have 
to pay for Platelet Rich Plasma provided from August 27, 2021, through September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee and vertical shock reducer pylon 
feature for a lower limb prosthesis. 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that these components are 
medically necessary. The Plan denied your request. The Plan says the denial of authorization for the requested 
components is correct, because these are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that lower limb prostheses and their components may be 
covered under certain clinical circumstances.  
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 lower limb prosthetic components. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested components. Our physician 
reviewer found the physician progress note does not support that the enrollee requires a Rheo microprocessor 
knee over a mechanical knee. Additionally, this knee has deluxe features that exceed the enrollee's medical 
needs. A vertical shock reducing pylon feature exceeds the enrollee's medical needs as the documentation does 
not reveal that the enrollee performs high impact activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a microprocessor knee and vertical shock reducer pylon feature for a 
lower limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that the Plan is putting undue hardship on the 
enrollee by demanding that the enrollee drive this distance. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the 
enrollee can be treated by an in-network chiropractor. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from the enrollees home who can provide chiropractic services. Under Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we decided 
that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network (OON) 
provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services (procedure code 99053) received on 
January 6, 2022. 
 
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 this was not reported correctly. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. The case file appears to show that you do not owe anything for the other code at issue in this case, CPT 99284. 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 medical 
services (procedure code 99053) received on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas treatment provided to the enrollee on July 9, 
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 this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We find that the denied codes are not supported in the medical record. Specifically, a review of the file and 
publicly available records show that the physical therapy services (97016, 97112, G0283) at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the state of Colorado.  
 
Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin 
syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. 
As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as 
billed, the drug administration code, 96372, also cannot be paid. 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 Sanexas treatment provided to the enrollee on 
July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, 
adjuvanted, for intramuscular injection (90750) provided January 14, 2022. 
 
You asked the Plan to pay for the injection. You say that it was medically necessary for you to receive this shot 
and you are asking for this to be covered under the medical or pharmacy benefits. The Plan denied your 
request. The Plan says this injection is not covered under the Part B drug benefit. This injection is only covered 
under the Part D prescription benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for 
intramuscular injection (90750) provided January 14, 2022.  
 Benefits for the injection 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is requested for the enrollee. 
The Plan denied your request. The Plan says the denial of authorization for LTACH is correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found all medically necessary care is being provided in the current acute care hospital. 
There are no services available at the LTACH which the enrollee requires that are not available in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87801) provided November 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 (87150, 87801) provided November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special urine testing. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is poor quality evidence for the utility of the testing in improving patient 
outcomes.  
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is not considered medically necessary for evaluation of someone with bladder infections. The test is 
not supported by current scientific data and lacks support in the current medical literature. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for special urine testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the MRI provided on December 27, 2021. 
 
You asked the Plan to waive the deductible for the MRI. You say that you only expected to pay the copay and 
no more under your plan. The Plan denied your request. The Plan says the deductible was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible that applies to Outpatient Diagnostics-Radiological 
Diagnostic Services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible that applies to MRIs. This cost sharing is a contractual 
obligation that had not been met at the time the MRI was received on December 27, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for the MRI provided on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided June 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 June 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis (74177) provided on November 19, 2021. 
 
You asked the Plan to pay for a CT scan of the abdomen and pelvis. You say that you have provided 
documentation to support the procedure at issue. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT scan of the abdomen and pelvis have not been met. Specifically, the Plan has documented 
that the claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and pelvis (74177) 
provided on November 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered not reasonable and necessary. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that the MyoPro 2 powered arm brace at issue in this case meets Medicare 
criteria for being medically reasonable and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with 
unproven benefit in the home environment. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or 
double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated 
(L8702) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on August 3, 
2021. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the therapeutic activities. Our reviewer says that CPT code 
97530 does not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 97530 requires direct one-on-one per the CPT code description. The therapy visit for this date of service, does not 
document therapy services were performed with direct one-on-one, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan 
does not have to pay for the therapeutic activities (97530) provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 20, 
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 laboratory testing related to treatment of end-stage renal disease is bundled into dialysis services 
and is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
laboratory services provided to the enrollee on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (81455) provided 
October 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this test is a proven and medically necessary 
covered benefit. The Plan denied your request. The Plan says targeted genomic sequence analysis panel is not covered by Medicare. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic 
decision making int the clinical management of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. 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 targeted genomic sequence analysis (81455) provided October 28, 2021.