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

 
We decided that the Plan does not have to pay for procedure codes 77063 and 77067 billed for date of service 
February 4, 2022. 
 You asked the Plan to pay for procedure codes 77063 and 77067. You say that the services at issue were billed 
correctly. The Plan denied your request. The Plan says payment for codes 77063 and 77067 is bundled into 
payment for code 77066. 
 
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 codes 
77063 and 77067 are column II codes to column I code 77066. These claim lines have 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 codes 77063 and 77067 billed for 
date of service February 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service November 
12, 2021. 
 
You asked the Plan to pay for procedure code 97110. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526. 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 97110 
is a column II code to column I code 92526. 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 97110 billed for date of service November 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 28, 2022. 
 
You asked the Plan to pay for the services provided. You say that the testing determined whether the enrollee 
was high risk for malignancy. The Plan denied your request. The Plan says there is no evidence to support the 
referring provider was treating the enrollee. 
 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. In this case, there are no medical records from the treating physician 
to that shows the intent for the testing to be performed. There are insufficient medical records to show how the 
testing will impact the management of a specific medical problem. Based on this information, we decided that 
the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab testing services provided on May 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (AED) rendered on 
March 12, 2021, and April 12, 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 claim was not filed timely. 
 
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 these services was not filed until September 1, 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 the automatic external defibrillator (AED) rendered on March 12, 2021, and 
April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction service (92015) provided on May 24, 2022. 
 
You asked the Plan to pay for the vision care. You say that this should be covered. The Plan denied your 
request. The Plan says refractive services are not covered under your medical benefit plan. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The Plan covers eye refractions when performed as part of a routine 
eye exam. Based on this information, we decided that the Plan's rules for coverage of the vision care have not 
been met. Specifically, the file does not support that the service in this case was performed as part of a routine 
eye exam. Therefore, we decided that the Plan does not have to pay for the refraction service (92015) provided 
on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on July 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you have used the same provider for 20 years. The 
Plan denied your request. The Plan says the hearing aids are not covered because they were provided OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use an approved audiologist in the Plans hearing network. 
 
We looked at the file and the Plan's rules. The provider in this case is not in the Plans hearing network. Based 
on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided on July 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 17, 2022, to 
June 22, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you had difficulty breathing, swollen 
legs, water retention, and a new diagnosis of atrial fibrillation while you were in the hospital. The Plan denied 
your request. The Plan says the self-administered drugs are not covered by Medicare or your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 17, 2022, to June 22, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services provided from February 14, 2022, to 
February 16, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that the Plan is fully at risk for this claim. 
The Plan denied your request. The Plan says that the claim processed correctly. 
 
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. Specifically, the Plan has failed to provide any explanation for its denial.  There 
are no Explanations of Benefits/Notices of Denial of Payment provided in the file it submitted to us.  There is 
no correspondence from the Plan or anything in the Plan's case narrative explaining why it denied this claim.  
The burden is on the Plan to support its denial.  By failing to provide any documentation explaining its denial, 
the Plan has not met this burden. Therefore, we decided that the Plan has to pay for emergency room services 
provided from February 14, 2022, to February 16, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Medicare-covered outpatient hospital 
facility visit provided on June 09, 2022. 
 
You asked the Plan to waive the copayment for a Medicare-covered outpatient hospital facility visit. You say 
that you scheduled a preventative colonoscopy and would like the copayment waived. 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 $290 
copayment for outpatient surgery. 
 
You have been asked to pay a $290 copayment for a Medicare-covered outpatient hospital facility visit. This 
item/service falls within the outpatient surgery 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 Medicare-covered outpatient hospital facility visit provided on June 09, 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 December 13, 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 a non-covered provider type. Additionally, the services in this case were not provided on the basis 
of a covered diagnosis. 
 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 case file and Medicare rules. Based on this information, we decided that the rules for 
coverage of the acupuncture services provided have not been met. Specifically, the acupuncture treatment in 
this case was not provided under the appropriate level of supervision of a physician, physician assistant, or 
nurse practitioner/clinical nurse specialist. Additionally, these services were not provided on the basis of a 
covered diagnosis. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment 
(97810, 97811) and the infrared therapy (97026) provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve the genicular radiofrequency ablation treatment. You say that the medical 
records provided will show proof of medical necessity. The Plan denied your request. The Plan says this 
procedure is experimental, investigational and unproven. There is not enough medical proof that shows the 
safety and/or success of this treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genicular radiofrequency ablation treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the destruction by neurolytic agent, genicular nerve branches including 
imaging guidance, when performed (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) battery 
backup. 
 
You asked the Plan to pre-approve a CPAP battery backup. You say that you use the CPAP machine daily to 
control your sleep apnea. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary.  
The file shows that you have a CPAP machine. Backup medical equipment is defined as an identical or similar 
device that is used to meet the same medical need for an enrollee but is provided for precautionary reasons to 
deal with an emergency when the primary piece of equipment malfunctions. Medicare does not pay separately 
or make an additional payment for backup equipment. This means the requested battery backup is not a 
covered benefit. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway 
pressure (CPAP) battery backup.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 
and influenza virus types A and B, multiplex amplified probe technique (87636) provided June 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this is an incorrect denial, and the claim 
needs to be reprocessed. The Plan denied your request. The Plan says service 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 record to determine if Medicare rules for coverage of the laboratory services have been met. 
Medicare records was needed and requested from the provider. The records show that the Plan made multiple 
attempts to obtain the records without success. Therefore, we decided that the Plan does not have to pay for the 
infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 
(SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified 
probe technique (87636) provided June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 2022. 
 
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 a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows that the services were not performed in the inpatient hospital setting. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on June 3, 2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that you had cervical cancer and hysterectomy 
surgery in 1995 and you have needed a pap smear every year since. The Plan denied your request. The Plan 
says the service is a covered benefit but the enrollee has exceeded limits set in the subscriber agreement. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy drug-metabolism testing (81232) billed for 
date of service June 14, 2022. 
 
You asked the Plan to pay for chemotherapy drug-metabolism testing. You say that the service at issue was 
billed correctly. 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 the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of chemotherapy drug-metabolism testing have not been met. Specifically, the medical records do not 
document that the specimen was collected on the reported DOS. The records do not support an exception to the 
rule. Therefore, we decided that the Plan does not have to pay for chemotherapy drug-metabolism testing 
(81232) billed for date of service June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service (00142) for eye surgery provided on 
April 26, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the vision care. You say that you do not understand why this was not covered. 
You say that you had surgery on your other eye, and it was covered. You also say that you were under the impression that all services were in-network with this facility. The Plan denied your request. The Plan says the 
provider in this case is out-of-network. The Plan also says you pay the full amount for vision care services 
received out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. When using an out-of-network provider for routine vision care, you 
will be responsible for costs above the plan approved amount. Based on this information, we decided that the 
Plan's rules for coverage of the vision care have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia service (00142) for eye surgery provided on April 26, 2022, by the out-of-
network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry, not 
elsewhere specified, analyte not elsewhere specified; quantitative, each specimen (83789) provided June 17, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that this claim is under-paid as not all codes 
(8278) were processed at their entirety. Please re-review the claim and reprocess for additional payment. The 
Plan denied your request. The Plan says this item or service does not meet the criteria for the category under 
which it was billed. 
 
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 record to determine if Medicare rules for coverage of the laboratory services have been met. 
Medical records were needed and requested from the provider. The records show that the Plan made multiple 
attempts to obtain the needed records without success. Therefore, we decided that the Plan does not have to pay 
for the mass spectrometry and tandem mass spectrometry, not elsewhere specified, analyte not elsewhere 
specified; quantitative, each specimen (83789) provided June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on June 9, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Percepta Bronchial Genomic Classifier is 
covered when Bronchoscopy is non-diagnostic. 
 
We looked at the file and Medicare rules. The records show that the bronchoscopy was diagnostic for 
malignancy. 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 (81479) provided on 
June 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
June 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under the Plan unless they are authorized by the Plan 
before the services are provided. 
 
 
 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 
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 subsequent nursing facility care (99309) 
provided on June 24, 2022, by an out-of-network (OON) provider.