Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visits (99600) provided from January 3, 2022, to 
January 7, 2022. 
 
You asked the Plan to pay for the home visits. You say that many calls to find an in-home caregiver went 
unanswered. You also say that the provider in this case was hired in good faith that the plan would cover the 
services. The Plan denied your request. The Plan says the provider in this case is not under contract with the 
plan. The Plan says that the provider is not certified for Medicare. The Plan also says there were in network 
providers available. 
 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 the home visits (99600) provided from 
January 3, 2022, to January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Procedure. 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that the Intracept Procedure is 
medically necessary. The Plan denied your request. The Plan says the Intracept Procedure is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer 
says that the Intracept Procedure not considered medically reasonable and necessary. Our physician reviewer 
found that the Intracept Procedure is experimental. More research is needed. 
 
 
 
 
 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 Intracept Procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Intracept Procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
December 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME. You say that the equipment was medically necessary. The Plan denied 
your request. The Plan says the rendering and referring providers are both OON providers and there was no 
approved authorization. 
  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 durable medical equipment (DME) provided 
on December 30, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurobehavioral status exam provided on March 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for neurobehavioral status exam. 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 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 neurobehavioral status exam provided on March 
11, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of abdomen and pelvis 
(74176) provided on January 16, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) scan of abdomen and pelvis 
(74176) provided on January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing billed for services provided on January 
6, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the claim was 
billed with a date inconsistent with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. There are insufficient medical records to show that the test was necessary 
for the treatment of an illness. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing billed for services 
provided on January 6, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says that SNF services are not medically necessary. The care can be met at a 
lower level. 
 
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 SNF 
services are medically necessary. Our physician reviewer found that the clinical documentation shows that you 
have multiple comorbidities which would require frequent assessment by skilled nursing and new functional 
impairments. The evaluating therapist states that you requires daily skilled therapy in a skilled nursing facility.  
From a practical standpoint you would require daily skilled services on an inpatient basis in a skilled nursing 
facility as recommended your care team thus it is 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 SNF services have been met. The Plan must continue coverage for the SNF 
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or 
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF 
services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 10, 2020. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes billed are 
included in the dialysis rate. The Plan denied your request. The Plan says claims for these services should be 
submitted to the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $15 copayments for radiation therapy performed from 
March 10, 2022, to April 29, 2022. 
 
You asked the Plan to waive the $15 copayments for radiation therapy. You say that you would like your 
copayments waived because this is a financial strain. The Plan denied your request. The Plan says you are 
responsible to pay a $15 copayment for in-network radiation therapy. 
 
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 $15 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $15 copayment per in-network radiation therapy. Radiation therapy falls 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 $15 copayments for radiation therapy performed from March 10, 2022, to April 29, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for lab work and an outpatient procedure 
provided from February 8, 2022, to February 17, 2022. 
 
You asked the Plan to waive the copayments for lab work and an outpatient procedure. You say that you should 
not have to pay either of these costs. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 $15 
copayment for labs and $250 an outpatient procedure for outpatient diagnostic tests and outpatient surgery.  
 
You have been asked to pay a $7.29 copayment for labs and $250 copayment for an outpatient procedure for 
lab work and an outpatient procedure ($7.25 is less than the allowed copayment amount of $15 for lab work. 
$7.29 + $250 = $257.29) Lab work and an outpatient procedure fall within the Outpatient Diagnostic Tests and 
Outpatient Surgery 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 copayments for lab work and an outpatient procedure provided 
from February 8, 2022, to February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on February 3, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. The CxBladder testing in this case was billed with code 0013M. Per 
LCD L35396, CxBladder testing is not covered when billed with code 0013M. 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 CxBladder testing (0013M) provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional miles one-way. 
 You asked the Plan to pre-approve additional one-way miles. You say that your next appointment is at the end 
of July. You also say that you need extended mileage to be approved. The Plan denied your request. The Plan 
says the transportation benefit only allows for 50 miles driving distance, one-way. The Plan also says that 
additional mileage is not approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip must not exceed 50 miles driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, additional mileage 
beyond the limit of 50 driving miles per trip are not covered. Therefore, we decided that the Plan does not have 
to pre-approve 8 additional miles one-way.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 21, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
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 procedure code 76705 billed for date of service February 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on October 8, 
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 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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine you received on January 10, 2022. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on January 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this was your annual exam so it 
should be covered in full. The Plan denied your request. Since services beyond a normal exam were addressed, 
it was not covered under the annual exam. The Plan says the copayment applied is correct. 
 
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 $10 
copayment for each primary care doctor office visit for Medicare-covered services.  
 
You have been asked to pay $10 copayment for office visit. 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 office visit provided on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 2, 2021 billed with 
codes 81227, 81241, 81328, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 81223, 81408, 
and 81291. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
must be billed with a single 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 
December 2, 2021 billed with codes 81227, 81241, 81328, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 
81350, 81479, 81223, 81408, and 81291.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 31, 2022, 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 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 office visit provided on March 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of prosthetic material/mesh (code 11008) provided 
on November 8, 2021. 
 
You asked the Plan to pay for removal of mesh. You say that you are disputing the processing of this claim. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 
11008 is an add-on code and was not billed with an appropriate primary procedure code. 
 
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 
removal of mesh is an add-on code and has not been billed with an appropriate primary procedure code. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for removal of prosthetic material/mesh (code 11008) provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image-guided radiation therapy (IGRT) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested service is not covered by Medicare or the health 
plan. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. In this case, the 
intent is clearly palliative, and it is not clear what benefit IGRT would afford. There is no specific justification 
for it in the case records. It seems as though IGRT is simply being used as routine practice, as there does not 
seem to be any exceptional circumstances with this patient necessitating the need for IGRT. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Image-guided radiation therapy (IGRT) for the enrollee.