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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 9, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 03, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment for denial of 
services rendered. The Plan denied your request. The Plan says if the enrollee needs Medicare-covered medical 
care and a network provider is unable to provide this care, the enrollee may be able to get care from an out-of-
network provider. Our plan must confirm there is not a network provider available and contact the plan to 
request authorization for the enrollee to obtain services from an out-of-network provider. If approved, the out-
of-network provider will be issued an authorization to provide the service(s). 
 
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 office visit provided on May 03, 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 office visit provided on December 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says e services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on December 21, 2021, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on May 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for eyeglasses. You say that you used this provider due to lower cost. The Plan 
denied your request. The Plan says services received out-of-network are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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 eyeglasses provided on May 11, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs provided on June 
10, 2022. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that the charges should be 
covered as in-network. 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 20% 
coinsurance for Medicare Part B chemotherapy drugs. 
 
You have been asked to pay 20% coinsurance for the chemotherapy drugs. This item/service falls within the 
Medicare Part B chemotherapy 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 
the chemotherapy drugs provided on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service October 1, 
2021. 
 
You asked the Plan to pay for procedure code 87634. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87634 is bundled into 
payment for code 87631. 
 
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 87634 
is a column II code to column I code 87631. 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 87634 billed for date of service October 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that there has been improvement in function 
over time, however clarification of the issue has helped to identify the next steps in his treatment plan. The Plan 
denied your request. The Plan says the health plan has no contractual obligation to cover services that are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 the additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested additional visits are not medically reasonable or necessary. Our physician reviewer 
found that the additional requested therapy generally is not accepted as specific and effective therapy for the 
patients condition beyond what was approved by the health plan. The patient has had prior therapy and the 
documentation does not reveal that the patient's requires the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist. The requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. The 
patient has been given ample time to transition to an independent home program. He can continue follow up 
with his physician for further evaluation. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy visits for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance -air provided on January 22, 
2022. 
 
You asked the Plan to waive the coinsurance for ambulance -air. You say that you shouldnt owe this amount. 
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 20% 
coinsurance for Ambulance services. 
 
You have been asked to pay 20% coinsurance for ambulance -air. This item/service falls within the Ambulance 
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 coinsurance for ambulance -air provided 
on January 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig purchased on December 10, 2021. 
 
You asked the Plan to pay for these services. You say that the item is necessary. The Plan denied your request. 
The Plan says the services are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig purchased on 
December 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency department services provided 
on June 10, 2022. 
 
You asked the Plan to waive the copayment for emergency department services. You say that the transportation 
service did not show up to take you home from your appointment, so you decided to walk. You also say that 
you were attacked by a dog on the way home and had to go to the emergency department. 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 $120 
copayment for per stay for each emergency room visit. 
 
You have been asked to pay a $120 copayment for emergency department services. This item/service falls 
within the per stay for each emergency room visit 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 emergency department services provided on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 25, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 25, 2022.
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 03, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be responsible for 
any cost share for the visits and services regarding your cataract surgery. You say that the second surgery was a 
result of an error with the first surgery. 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 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an office visit. This item/service 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 an office visit provided on February 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on December 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99291 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care spent on the enrollee. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the critical care services rendered on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist hand orthosis, includes one or more nontorsion 
joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf provided to 
the enrollee on June 13, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is evidence of misrepresented services. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records document a medical evaluation for hand/wrist pain with imaging showing mild 
degenerative changes and chondrocalcinosis. Analgesics were recommended as well as referral to a hand 
specialist, but no records have been provided documenting that the treating provider recommended treatment 
with a wrist hand orthosis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may 
include soft interface, straps, prefabricated, off-the-shelf provided to the enrollee on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute. 
 
You asked the Plan to pre-approve skin substitute. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 pre-approve skin substitute. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation did not clearly describe the enrollee with controlled diabetes via 
lifestyle changes and medication, and there was insufficient documentation showing adequate perfusion to the 
wound to justify grafting at this stage. Therefore, based on the provided documentation, this request for skin 
graft will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 22, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is blind, incontinent, and not able to 
function at all. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, the enrollee no longer qualifies for SNF 
coverage. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 13, 2022, billed 
with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
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 February 13, 2022, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, 81194 and 81309.