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

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service March 29, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. You have verbally indicated that there could have been an error in billing two units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value can only be paid when the MAI value is 3 when there is adequate documentation of the 
necessity of additional units for the same date of service.  
 
In this case, the MUE for CPT code 70450-26 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You have not provided any argument to support additional units of code 70450-26. 
Based on this information, we decided that Medicare rules for coverage of procedure code 70450-26 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date 
of service March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are requesting the Plan to waive the no prior 
authorization based on medical necessity. The Plan denied your request. The Plan says the rendering provider 
is an OON provider and there was no referral from an in-network provider or an approved authorization. Also, 
the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided April 6, 
2022, to April 28, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the charges are medically 
necessary, therefore all charges should be paid in full. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided April 6, 2022, to April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed for 
date of service June 13, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that you mail out the product before billing to ensure 
that the patient has received it and is satisfied. The Plan denied your request. The Plan says the date of service 
on the claim is not correct. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service to be entered on the claim 
should be either the date that the patient receives the item, or the date that the item was shipped.  In this case, 
records show that the item was shipped on June 3, 2022, and delivered on June 9, 2022.  Neither of these dates 
match what you have billed on the claim (June 13, 2022). We looked at the file and Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies 
billed for date of service June 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 4, 2022, to April 13, 
2022, by an OON provider. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on April 4, 2022, to 
April 13, 2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76700) provided on March 27, 2022. 
 
You asked the Plan to pay for procedure code 76700. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 7, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for procedure code 76700 have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound (76700) provided on March 27, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 12, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a pharmacogenetics panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on April 12, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from December 28, 2021, to 
April 19, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says prior approval 
process was not followed. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided from December 28, 2021, to  
April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided on April 1, 2022. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the seat lift was medically necessary and 
should be covered. The Plan denied your request. The Plan says the equipment was purchased from a provider 
that does not participate in Medicare. Payment cannot be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided 
on April 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician visit in a SNF provided on May 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a physician visit in a SNF. You say that you disagree with the denial and would 
like the claim to be reviewed and reprocessed for payment. The Plan denied your request. The Plan says an 
authorization was not obtained prior to services 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 physician visit in a SNF provided on May 31, 
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 lab services (81479) provided on February 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was billed with an incorrect DOS. 
 
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. There is no documentation describing genetic testing on a sample 
collected on the date of service at issue. 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 the 
lab services (81479) provided on February 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on February 02, 2022, to 
February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says as a member of our plan, the enrollee must use network providers. If 
the enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and the 
enrollee will be responsible for the entire cost. 
 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 skilled nursing facility provided on February 02, 
2022, to February 23, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 2, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that the patient had multiple visits on the same 
day. The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 
99285. 
 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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service July 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided on April 
21, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you are requesting a 
reconsideration of her cost-share charges. 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 40% 
coinsurance for out-of-network inpatient hospital care/provider and professional services.  
 
You have been asked to pay a 40% coinsurance for inpatient hospital care. The total allowed amount for the 
inpatient hospital care is $99.14. The amount you are being asked to pay is $39.66 ($99.14 x 40% = $39.66). 
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 inpatient hospital care provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy (97124) provided on June 29, 2022. 
 
You asked the Plan to pay for the massage therapy. You say that this was necessary to relieve your hip pain. 
You say that this was very helpful for your healing. You also say that this should be paid as it is a medical 
concern. The Plan denied your request. The Plan says massage therapy is not a covered service. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for the massage therapy (97124) provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient visit provided on April 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a new patient visit. You say that this should be covered, you are under 'pending' 
status for being a contracted provider. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 new patient visit provided on April 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
(code A0998) provided on June 14, 2022. 
 
You asked the Plan to pay for ambulance response and treatment with no transport. You say that the ambulance 
services were medically necessary. The Plan denied your request. The Plan says Medicare does not cover this 
service. The beneficiary is liable for the cost of ambulance response and treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 14, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport (code A0998) provided on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
June 30, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would 
like to appeal the cost share. 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 $200 
copayment for a computerized tomography (CT) scan.  
 
You have been asked to pay a $200 copayment for a computerized tomography (CT) scan. This item/service 
falls within the a computerized tomography (CT) scan 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 computerized tomography (CT) scan on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemodialysis services (90935) provided on March 10, 
2022. 
 
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 this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on April 28, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the hemodialysis services (90935) provided on March 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 17, 2021, billed 
with codes 81225, 81227, 81226, 81230, 81231, 81291, 81328, 81335, 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that these codes are allowable and payable. 
The Plan denied your request. The Plan says a single unit of 81479 represents one multigene test.  Billing each 
gene individually is incorrect coding. 
 
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 
September 17, 2021, billed with codes 81225, 81227, 81226, 81230, 81231, 81291, 81328, 81335, 81355.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment provided on July 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the opioid treatment. You say that you are substance abuse and mental health 
services administration certified and would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the opioid treatment provided on July 11, 2022, by 
an out-of-network (OON) provider.