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

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
February 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this letter documents the medical necessity 
of the test requested to assist in the treatment, prognosis and diagnosis of their cancer. The Plan denied your 
request. The Plan says coverage/program guidelines were not met. 
 
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 find that CPT code 81479 is not supported in the medical record. Specifically, the specimens 
were collected on December 16, 2021, and January 28, 2022, rather than the billed date of service February 9, 
2022. There is no documentation to support genetic testing with the billed date of service. 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 unlisted molecular pathology procedure 
(81479) provided February 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on February 11, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were incorrectly billed with the -TC 
modifier. Therefore, we decided that the Plan does not have to pay for the testing services rendered on 
February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance, oral hygiene instructions, 
periapical images and 2D oral/facial images on March 8, 2022. 
 
You asked the Plan to pay for periodontal maintenance, oral hygiene instructions, periapical images and 2D 
oral/facial images. You say that you would like to request reconsideration of the denied claim. The Plan denied 
your request. The Plan says the member's plan does not cover these services. Our records indicate you did not 
contact the plan prior to the date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance, oral hygiene instructions, periapical images and 2D oral/facial images on March 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens (S0580), frames (V2020), anti-
reflective coating (V2750), UV lens (V2755), and progressive lens (V2781) provided on April 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the glasses. You say that according to your benefit coverage you have a $150 
allowance for frames, and progressive lenses are covered in full. You also say that the treating provider is in-
network. The Plan denied your request. The Plan says the treating provider is not a Plan-approved vision 
network provider. The Plan also says that you did not contact the Plan prior to obtaining these glasses. 
 
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 they are purchased from a Plan-approved Vision network 
provider. 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received these services from 
an OON provider. Based on this information, we decided that the Plan's rules for coverage of the glasses have 
not been met. Therefore, we decided that the Plan does not have to pay for the polycarbonate lens (S0580), 
frames (V2020), anti-reflective coating (V2750), UV lens (V2755), and progressive lens (V2781) provided on 
April 6, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for fillings (D2392 x2) received on January 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that the provider was 
out-of-network. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for fillings (D2392 x2) received on January 26, 
2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services rendered on February 8, 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 that a corrected claim with correct HCPCS codes is needed. 
 
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. The Plan states that the claim was reprocessed on May 6, 2022 but is still denied 
due to needing a corrected claim with correct HCPCS codes. The Plan has not provided further explanation or 
documentation of the billed codes or Medicare rules to support that the codes were not properly billed. 
Therefore, we decided that the Plan has to pay for the emergency room (ER) services rendered on February 8, 
2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service December 
22, 2021. 
 You asked the Plan to pay for procedure code 99220. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 99220 is bundled into payment 
for code 93018. 
 
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 99220 
is a column II code to column I code 93018. 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 99220 billed for date of service December 22, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 1, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility. You say that due to the place of service settings, it is 
not always possible to obtain an authorization for every visit prior  to the provider rendering the services. The 
Plan denied your request. The Plan says a review confirmed that there was no prior authorization submitted to 
the Plan to request coverage for out-of-network care with skilled nursing facility wound care service. The Plan 
also says that the member was in a skilled nursing facility stay that was not covered by them. 
 
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 subsequent nursing facility care provided on 
March 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (U0003) provided on August 25, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this is not a 
covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that code U0003 is assigned a status indicator of "X" under the 
Physician Fee Schedule, which is true, however, the services were billed by a laboratory. This code is payable 
under the Clinical Laboratory Fee Schedule. The Plan has not provided documentation to support its denial. 
Therefore, we decided that the Plan has to pay for the lab services (U0003) provided on August 25, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation services. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation services. You say that non-
emergency ambulance services are necessary for your doctor appointments based on the condition you are in. 
The Plan denied your request. The Plan says non-emergency ambulance transportation is not medically 
necessary for the enrollee's condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation services. Our reviewer says that the requested non-emergency ambulance transportation services 
are not medically reasonable and necessary. Our physician reviewer found that the documentation does not 
support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of 
vehicle) were contraindicated for the enrollee. The documentation states that the enrollee ambulates with a 
walker. Other means of transport would be reasonable and safe for transportation. The documentation does not 
support that the enrollee needs the expertise, services and lifesaving and life-sustaining equipment that only a 
fully-equipped ambulance can provide for safe transport. The documentation does not support that the 
ambulance transport is medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation services have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transportation 
services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on February 10, 2022. 
 You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications.  
 
We looked at the file, and Medicare rules. In this case, the records provided do not include medical records, 
including a treatment plan, for the enrollees cancer. 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 
FoundationOne testing provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 10, 
2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that your dental plan has always allowed you 
two free cleanings a year. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) and 
debridement, subcutaneous tissue (11042) provided on February 8, 2022, to February 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that it is not always possible to obtain an 
authorization for every visit prior to the provider rendering services, which means you will need to send in 
medical records to show the necessity of providing services to the enrollee. 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 subsequent nursing facility care (99308) and 
debridement, subcutaneous tissue (11042) provided on February 8, 2022, to February 17, 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 genetic testing provided on March 21, 2022 billed with 
codes 81162, 81201, 81292, 81295, 81298, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 21, 2022 billed with codes 81162, 81201, 81292, 81295, 81298, and 81317.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interrogation device evaluation provided on April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an interrogation device evaluation. 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 can be received in-network. 
 
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 an interrogation device evaluation provided on 
April 11, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a modifier 
was not billed to represent the services as separate/distinct. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 
billed for date of service March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid batteries (V5266) provided on January 5, 2022. 
 
You asked the Plan to pay for hearing aid batteries (V5266). The Plan denied your request. The Plan says 
procedure code V5010 has been overturned and procedure code V5266 remains denied as a non-covered 
benefit. 
 
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 plan's coverage rules apply in this case. The Plan only covers 
up to $2,400 for hearing aids every year.  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aid batteries (V5266) have not been met. Specifically, hearing aid batteries are not a covered benefit. Therefore, we decided that the Plan does not have to pay for hearing aid batteries (V5266) 
provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on September 14, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
have pulmonary embolism and your medical providers warned you about the dangers of falling without seeking 
medical attention immediately. The Plan denied your request. The Plan says there is no clinical documentation 
that would qualify as criteria for the use of an emergency ambulance as means of transport to the emergency 
department. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 emergency ambulance transportation and 
ground mileage. Our reviewer says that the emergency ambulance transportation was not reasonable and 
necessary. Our physician reviewer found you were able to ambulate both before and after ambulance transport, 
with no complaints of injury, and the ambulance rendered no medical care beyond basic screening exam and 
transportation. Our reviewer also found that upon arrival at the hospital, you were taken to the ambulatory 
patient registration and triage at the front desk at the front of the emergency room, rather than being placed in a 
patient room. 
 
 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 emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation 
(A0429) and ground mileage (A0425) provided on September 14, 2021.