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

 
We decided that the Plan has to pay for targeted genomic sequence analysis testing (code 81455) provided on 
December 1, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing meets medical necessity. The Plan 
denied your request. The Plan says that the denial of payment for this code is correct, because code 81455 is 
not covered by Medicare. 
 
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 claims that code 81455 is not covered by Medicare. Based on Medicare 
rules, however, code 81455 was a Group 1 covered code applicable to date of service December 1, 2021. 
Therefore, the Plans denial on this basis is not supported. The Plan provided no other evidence or rationale to 
support a denial of payment for this test. Therefore, we decided that the Plan has to pay for targeted genomic 
sequence analysis testing (code 81455) provided on December 1, 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 the moderate sedation services (99153) provided on October 
6, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that the documentation supports 
that the procedure was performed in the emergency room by the emergency room provider. You say that claim 
should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says as CPT code 
99153 is a technical component only code, it should be reported by a MAC Part A or B hospital setting. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a 
technical component only code and the claim indicates that this service was rendered in a facility setting. 
Payment for CPT code 99153 is made to the facility and is the responsibility of the facility to any physician or 
vendor. Based on this information, we decided that Medicare rules for coverage of the moderate sedation 
services (99153) have not been met. Therefore, we decided that the Plan does not have to pay for the moderate 
sedation services (99153) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 24, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were sent to the urgent care by 
your primary care physician because they had no openings for three days. The Plan denied your request. The 
Plan says you were charged the correct cost sharing amount. 
 
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 $65 
copayment for each urgent care visit.  
 
 
 
 
 
 You have been asked to pay a $65 copayment for an office visit. An office visit falls within the urgently needed 
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 an office visit provided on 
February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 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 the lab services provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
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 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 the drug testing services provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 29, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the FANCC is not a Medicare benefit 
and is a statutorily excluded service  
 
 
 
 
 
 
 We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC testing is not covered. 
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 genetic testing provided on November 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a rituximab injection (J9312) provided on 
April 28, 2021, and May 14, 2021. 
 
You asked the Plan to waive the coinsurance for the rituximab injection. 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 rituximab injections (total coinsurance $2,806.16). 
Rituximab injection falls 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 a rituximab injection (J9312) provided on April 28, 2021, and May 
14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a radiologic examination of the wrist and a 
radiologic examination of the hand provided on January 25, 2021. 
 
You asked the Plan to waive the copayment for a radiologic examination of the wrist and a radiologic 
examination of the hand. You say that if there was no fracture found from the initial x-ray, you would not have 
needed to go to the emergency room (ER) for the splint/cast. You also say that you feel that the x-ray service 
and the ER services should be considered one same day incident and not charging you 2 separate copayments. 
The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 $50 
copayment for x-rays for outpatient diagnostic tests and therapeutic services and supplies.  You have been asked to pay a $50 copayment for a radiologic examination of the wrist and a radiologic 
examination of the hand. A radiologic examination of the wrist and a radiologic examination of the hand fall 
within the outpatient diagnostic tests and therapeutic services and supplies 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 radiologic examination of the wrist and a radiologic examination of 
the hand provided on January 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76700) provided on January 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 76700 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 the services (76700) 
provided on January 11, 2022.
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 an IRF admission. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's 
ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for skilled nursing facility (SNF) provided from 
January 3, 2022, to January 13, 2022. 
 
You asked the Plan to waive the deductible for the SNF services provided. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $700 deductible which applies to Skilled nursing facility (SNF) care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Skilled 
nursing facility (SNF) care. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $700 deductible which applies to Skilled nursing facility (SNF) care. This cost sharing is a 
contractual obligation that had not been met at the time the SNF services provided was received on January 3, 
2022, to January 13, 2022. Therefore, we decided that the Plan does not have to waive the deductible for skilled 
nursing facility (SNF) provided from January 3, 2022, to January 13, 2022.  
 
Since the deductible was met, you have also been asked to pay a $2,972.90 coinsurance for the SNF services. 
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 cost share for SNF care provided from January 3, 2022, to January 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
(99072) provided on October 6, 2021. 
 
You asked the Plan to pay for the additional supplies, materials, and clinical staff time (99072). You say that 
the documents required to reprocess the denied claim are attached. You say that you expect 30% payment of 
the billed charges. The Plan denied your request. The Plan says procedure code 99350 has been paid and 
procedure code 99072 remains denied as bundled services are not eligible for separate reimbursement.  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 code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies, materials, and clinical staff time (99072) have not been met. Therefore, we decided 
that the Plan does not have to pay for the additional supplies, materials, and clinical staff time (99072) provided 
on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
February 17, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you had the same kind 
of telehealth visit with a different provider last year and there was no copayment for that visit. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $30 
copayment for a specialist telehealth visit.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$30 copayment for a specialist telehealth visit. A specialist telehealth visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist telehealth visit provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic Care provided on March 1, 2022 to April 1, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Chiropractic Care. You say that you would like to appeal the denial of the claim 
and that you didn't know prior authorization was required. The Plan denied your request. The Plan says the 
provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 Chiropractic Care provided on March 1, 2022 to 
April 1, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 4, 2021 to December 
13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were 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 November 4, 2021 to 
December 13, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis (J2778). 
 
You asked the Plan to pre-approve Lucentis. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been 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 Lucentis. Our reviewer says that the 
requirements for coverage of Lucentis have not been met. Our physician reviewer found the Plan requires a 
trial of Avastin (bevacizumab) before they will approve the requested drug. The records do not show that you 
have tried this drug, that this drug would likely be less effective, or that this drug would have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis (J2778).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on January 18, 
2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 $30 
copayment for Outpatient hospital services.  
 
You have been asked to pay a $30 copayment for the laboratory services. Laboratory services fall within the 
Outpatient hospital 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 laboratory 
services provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on 
February 1, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall within 
the Physician/Practitioner services, including doctors office visits 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 specialist office visit (99213) provided on February 1, 2022.