Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation services billed with code 99254 for date of 
service March 29, 2022. 
 
You asked the Plan to pay for code 99254. You say that you disagree with the PLan's denial because this was a 
direct admit from the emergency room. The Plan denied your request. The Plan says you billed with an 
incorrect code. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 1, 2010, consultation codes are 
no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management 
(E/M) visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit 
performed. The code you billed (99254) is a consultation code, meaning it is no longer recognized. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99254 have not been met. Therefore, we decided that the Plan does not have to pay for the 
consultation services billed with code 99254 for date of service March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 12, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says you are not a licensed Medicare eligible provider. 
 
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 is not a Medicare eligible provider.  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 pay for lab 
services provided to the enrollee on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on October 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 procedure code 98971 is 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 98971 is qualified nonphysician health care professional 
online digital assessment and management, for an established patient, for up to 7 days, cumulative time during 
the 7 days; 11-20 minutes. 
 
We find that CPT code 98971 is not supported in the medical record. Specifically, there are no submitted 
records to support the services as billed. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services rendered on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased on March 1, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that your former employer told you that hearing aids 
would be covered under your policy.  You said that you were never told that you needed to use a network 
provider. The Plan denied your request. The Plan says you did not use the Plan's designated hearing aid vendor. 
 
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 purchased from the Plan's designated hearing aid vendor.  You did not use the Plan's 
designated hearing aid vendor to purchase the hearing aid in dispute. 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 hearing aids you purchased on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Allosure testing provided on March 9, 2021. 
 
You asked the Plan to pay for the Allosure testing. You say that this claim denied incorrectly.  You said that 
this service should be paid because it is covered by Original Medicare. The Plan denied your request. The Plan 
says it cannot determine the necessity of this testing. 
 
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 Allosure testing provided on March 9, 
2021. have been met. Specifically, you have provided no medical records to support payment for this testing despite multiple requests from the Plan.  Without medical records, we cannot determine if Allosure testing was 
medically necessary and appropriate for this patient. Therefore, we decided that the Plan does not have to pay 
for Allosure testing provided on March 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 29, 
2021. 
 
You asked the Plan to pay for procedure code 76705. You say that this code should not be bundled. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service October 29, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493, 64494, and 99151 billed for date of 
service February 7, 2022. 
 
You asked the Plan to pay for procedure codes 64493, 64494, and 99151. You say that these services were 
billed correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed for codes 64493 and 64494.  The Plan says that code 99151 is not appropriate for the services 
rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 64493 and 64494 is 1. The MAI value for these codes is 2. You billed 2 
units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 64493, 64494, and 99151 have not been met. 
 
In addition, you billed code 99151 which is defined as for the first 15 minutes of intraservice time for sedation 
services rendered to a patient younger than 5 years of age.  However, the patient in this case was 66 years of 
age, so there is a different code that should have been used for this service. Therefore, we decided that the Plan 
does not have to pay for procedure codes 64493, 64494, and 99151 billed for date of service February 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound you had on May 20, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you disagree with this bill. The 
Plan denied your request. The Plan says you were charged this copayment 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 $115 
copayment for radiological diagnostic services performed in a physician's office or a free-standing facility.  
 
You have been asked to pay a $115 copayment for the ultrasound. The ultrasound falls within the radiological 
diagnostic 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. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound you 
had on May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for the face-down positioning device you rented on 
January 14, 2022. 
 
You asked the Plan to pay for to pay for the face-down positioning device. You say that you were told this 
would be reimbursed. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that face-down positioning devices are statutorily 
non-covered. That means that this item is not covered regardless of medical necessity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of to pay for the face-down positioning device have not been met. Therefore, we decided that the Plan 
does not have to pay for to pay for the face-down positioning device you rented on January 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound you had on April 22, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the provider told you that you only 
had a $15 copayment.  You do not feel as though you should have to pay anything else. The Plan denied your 
request. The Plan says you were charged this copayment 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 $85 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $85 copayment for the ultrasound. The ultrasound falls within the radiological 
diagnostic 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. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound you 
had on April 22, 2022.  
 Your complaint about the provider giving you incorrect information is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network urology services provided to the enrollee on 
April 11, 2022. 
 
You asked the Plan to pay for these services.. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the 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 out of network urology services provided to the 
enrollee on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on February 12, 2022 to 
March 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON acupuncture services. You say that you went to a provider with better 
experience in acupuncture, so this should be covered. The Plan denied your request. The Plan says 
unauthorized, non-plan 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 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 acupuncture services provided on February 12, 
2022 to 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 rendered on February 22, 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 all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on February 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services received on May 28, 2021. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the patient was enrolled in hospice on 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 medical services received on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84165-26 billed for date of service February 
16, 2022. 
 
You asked the Plan to pay for procedure code 84165-26. You say that these services were medically necessary 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 84165-26 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 84165-26 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 84165-26 billed for date of service February 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupizent. 
 
You asked the Plan to pre-approve Dupizent. You say that the enrollee requires this drug for the treatment of 
atopic dermatitis. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 pre-approve Dupizent.  
 
Benefits for Dupizent 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 disturbances of 
salivary secretion with drooling. He has not tried and failed the Plan's required drugs, Botox or Xeomin. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, the Myobloc 
is not reasonable or medically necessary. 
 
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 Myobloc.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial of skilled nursing 
facility admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an 
admission to a skilled nursing facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was at contact guard to minimal assist level with functional mobility 
including gait to 200 feet. The enrollee required varying assist with activities of daily living. The enrollee does 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the enrollee does] 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to hold the enrollee harmless for the walker brakes received on March 10, 2022. 
 
You asked the Plan to hold the enrollee harmless for the walker brakes. You say that these should be covered as 
part of the walker since they are needed to use the walker. The Plan denied your request. The Plan says that the 
walker brakes are not separately payable according to Medicare rules. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was provided the walker brakes by a contract provider. The file does not show that the plan or the 
provider provided notice that the walker brakes would not be covered. Under Medicare rules, this means the 
walker brakes is considered approved by the plan. We agree that typically walker brakes are not separately 
payable.  However, that is not the enrollee's issue- the Plan provider should not have billed these brakes 
separately in this manner.  The Plan has an obligation to ensure that the enrollee is not penalized for the billing 
errors of their own plan providers. Therefore, we decided that the Plan has to hold the enrollee harmless for the 
walker brakes received on March 10, 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 lab services provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the lab services you provide are medically 
appropriate and should be paid. The Plan denied your request. The Plan says unauthorized, non-plan services 
are 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. 
 
Neither your lab nor the ordering provider is 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 lab services provided on March 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that the medical records support the claim. 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 1, 2022.