Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the psychotherapy services (90832) provided from March 2, 2022, to 
March 16, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have been met. Specifically, the record shows that the enrollee was 
referred to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay 
for the psychotherapy services (90832) provided from March 2, 2022, to March 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation. Since he had 
COVID-19 a month ago, mobility has declined and needs therapy to be able to walk again. The Plan denied 
your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of the enrollee's nursing medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has experienced a progressive decline in function and strength due to COVID-19. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program at 
least three hours a day and five days a week, or 15 hours over seven consecutive days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
January 29, 2022. 
 
You asked the Plan to pay for the non-covered ambulance mileage. The Plan denied your request. The Plan 
says your Plan covers ambulance transportation only when you are actually transported by ambulance. The 
Plan also says that since you were not transported by this ambulance, the service is not covered by your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare law contains a restriction that miles 
beyond the closest available facility cannot be billed to Medicare. 
 
We looked at the file and Medicare rules. The record shows that it was requested you be taken to the further 
facility, you were informed of the non-coverage of the additional miles, and agreed to be transported anyway. 
Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage 
have not been met. Therefore, we decided that the Plan does not have to pay for the non-covered ambulance 
mileage (A0888) provided on January 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for leuprolide acetate injections (J9217) 
provided on December 20, 2021, and March 21, 2022 
 
You asked the Plan to waive the coinsurance for the leuprolide acetate injections. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for two leuprolide acetate injections (total allowed is $1,018.41 
x 20% = $203.68). Leuprolide acetate injections fall within the Medicare Part B prescription drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for leuprolide acetate injections (J9217) provided 
on December 20, 2021, and March 21, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nodify CDT test provided on June 30, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
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 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 that it has not been demonstrated that Nodify CDT testing adds to standard care risk assessment methods 
for determining risk of malignancy for 8-30 mm pulmonary nodules in asymptomatic patients. Nodify CDT's 
clinical utility has not been established in the medical literature. The test is not FDA-approved for the requested 
risk assessment testing.  
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 the Nodify CDT test provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 23, 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 you billed with an incorrect place of service on the claim. 
 
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 on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84460) provided January 10, 2022. 
 
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 number of units billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 84460 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 84460. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(84460) provided January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the platelet-rich plasma injections (0232T) provided on 
January 31, 2022. 
 
You asked the Plan to pay for code 0232T. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that upon reconsideration, The Centers for Medicare 
and Medicaid Services (CMS) has determined that platelet-rich plasma (PRP) - an autologous blood-derived 
product, will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure 
wounds. 
 
We looked at the file and Medicare rules. The file shows that the platelet rich plasma injections were provided 
to treat knee pain. Medicare excludes coverage of platelet rich plasma injections for this condition. 
 Therefore, we decided that the Plan does not have to pay for the platelet-rich plasma injections (0232T) 
provided on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on December 29, 2021. 
 You asked the Plan to pay for the services provided. You say that the testing is reasonable for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the test is statutorily excluded. 
 
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. The records show that the gene panel at issue includes the FANCC 
gene. Panels of tests that include the FANCC gene are a statutorily excluded service. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided on March 1, 2022. 
 
You asked the Plan to pay for the wrist hand orthosis. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services 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 wrist hand orthosis (L3916) 
provided on March 1, 2022, have been met. In this case, there is no mention in the provided medical records for the need of the item provided. Therefore, we decided that the Plan does not have to pay for the wrist hand 
orthosis (L3916) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement and office visit services (11042 and 99214) 
provided on December 15, 2021. 
 
You asked the Plan to pay for codes 11042 and 99214. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The surgical procedure and office visit in question (codes 11042 and 
99214) were provided within the 90-day global period for the surgical procedure (code 28810) that was 
provided on October 26, 2021. This means that payment for codes 11042 and 99214 were included in the 
payment for code 28810. Codes 11042 and 99214 were not billed with an appropriate modifier indicating that 
the services were unrelated and rendered during the postoperative period of the global procedure. Therefore, we 
decided that the Plan does not have to pay for the debridement and office visit services (11042 and 99214) 
provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
November 22, 2021. 
 
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 23. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on March 3, 2022, by an out-of-network 
provider. 
 You asked the Plan to pay for eyeglasses. You say that you found a better deal from this provider and would 
like a one-time exception. The Plan denied your request. The Plan says out-of-network eyewear is not covered 
by your 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 up to $200 when they are received from a provider within the Plan's 
specified routine vision vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified network. 
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on March 3, 2022, by an out-
of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 18, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 32555. 
 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 71045 
is a column II code to column I code 32555. 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 71045 billed for date of service February 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services coded 80053, 85025, and 
G0463 provided on October 7, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 80053, 85025, and G0463 are not supported in the medical record. Specifically, the 
Non-Participating facility billed outpatient services which are within the 3 day payment window policy for 
outpatient services to be treated as inpatient services for a billed inpatient Part A claim for dates of service, 
October 07, 2021 through October 10, 2021. All diagnostic and outpatient non-diagnostic services related to 
the inpatient admission that fall on the date of the enrollees inpatient admission or during the 3 calendar days preceding the date of admission are required to be bundled on the Part A bill for the inpatient stay and an 
attestation to specific non-diagnostic services as being unrelated to the hospital Part A claim using condition 
code 51 was not reported on the outpatient claim. Therefore, per the above guidelines we find the Medicare 
rule for reimbursement of this October 07, 2021, claim has not been met. Based on this information, we 
decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services coded 80053, 85025, and G0463 
provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on May 4, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says although hearing aids are a covered benefit 
under this Plan, they must be purchased through the Plan's 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 they are purchased from the Plans hearing aid vendor.  
 
We looked at the file and the Plan's rules. In this case, the hearing aids in question were not purchased from the 
Plans hearing aid vendor. 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 
purchased on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99214) provided on January 25, 
2022 to March 22, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that the claim denied because it was assumed that a 
nurse practitioner saw this enrollee when in fact it was the doctor. Please reconsider this claim. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visits (99214) provided on 
January 25, 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 gene panel testing provided on March 24, 2021. 
 
You asked the Plan to pay for the testing services. You say that the physician ordered the test to determine the 
best course of treatment. The Plan denied your request. The Plan says one code must be submitted for the 
panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 The claim information shows that the gene panel was billed with multiple codes. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel (0242U) 
provided on September 21, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that the services should 
be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 a targeted genomic sequence analysis panel 
(0242U) provided on September 21, 2021 by an out-of-network (OON) provider.