Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the joint injection provided on December 3, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON joint injection. You say that this was a medically necessary treatment 
and should be paid without authorization. The Plan denied your request. The Plan says non-emergency services 
from OON providers are only covered if authorization is obtained. 
 
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 joint injection provided on December 3, 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 the rural health clinic of federally qualified health center 
services (CPT code G0511) provided on November 2, 2020. 
 
You asked the Plan to pay for the services. You say that the primary care physician was updated and rebilled as 
corrected claim, but the claim denied for the same reason. The Plan denied your request. The Plan says 
according to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
services was not filed until January 21, 2022. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
rural health clinic of federally qualified health center services (CPT code G0511) provided on November 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the varicose vein treatment provided on January 8, 2022, 
billed with code 36475-LT-79. 
 
You asked the Plan to pay for the medical services as billed. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says the modifier -79 is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The services were billed with modifier -79 which is only appropriate when the service is being done within the 
postoperative period of prior procedure. There is no evidence that this service was performed within the global 
period of another procedure, which does not support the use of modifier -79. Based on this information, we 
decided that Medicare rules for coverage of the medical services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the varicose vein treatment provided on January 8, 2022, billed 
with code 36475-LT-79.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81455, 81479-XU, 
81301-XU, 81194-XU, and 81479-XU) provided on July 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The denial remains 
upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one CPT code must be submitted for the panel. 
 
CPT code(s) 8145, 81301XU, and 81194XU, remain not supported. The place of service on the CMS-1500 
form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim 
form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, 
the laboratory results submitted indicate the specimen was collected on July 21, 2021, and received by the lab 
on July 22, 2021. Of note, the patient resides in North Carolina and the billing laboratory is located in 
Alabama; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain 
additional information from the provider. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 81455, 81479-XU, 81301-XU, 81194-XU, and 81479-XU) provided on July 
21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you would like the notes and evaluation to be 
reviewed for continued skilled rehabilitation services. The Plan denied your request. The Plan says the Skilled 
Nursing Facility (SNF) services you are requesting do not meet the requirements for approval. 
 
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 services. Our reviewer says that 
you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do did not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of baroreflex activation device 
(0266T). 
 
You asked the Plan to pre-approve the implantation of baroreflex activation device (0266T). You say that 
studies have shown that patients with the Barostim system implant experienced significant improvement in 
quality of life. You say that the device is safe with very few complications and the medical records support the 
medical necessity of Barostim therapy. The Plan denied your request. The Plan says this system is considered 
investigational and/or experimental. 
 
  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 implantation of baroreflex 
activation device (0266T). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there remains an absence of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim 
Neo in patient management. 
 
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 implantation of baroreflex activation device (0266T) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the implantation of baroreflex activation 
device (0266T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 
83550, 83970, and 84100) provided on October 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The documentation 
submitted showed that the laboratory tests reported were related to treatment of ESRD since end-stage renal 
disease was indicated as a reason for the laboratory tests and a separate professional visit unrelated to ESRD 
was not indicated in the medical record. Therefore, the laboratory tests are included in the dialysis services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 
82728, 83540, 83550, 83970, and 84100) provided on October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on October 4, 
2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that providers were treating the patient 
under a different specialty for a different diagnosis. The Plan denied your request. The Plan says the claim was 
already paid on October 15, 2021 however, the Plan did not see that money was retracted on October 19, 2021. 
 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 99231 is defined as subsequent hospital care. 
 
We asked our coder 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 subsequent hospital care. Our reviewer says that the 
services at issue in this case are not supported by the medical records. Our reviewer found the clinical notes 
submitted for October 4, 2021 are for a Tracheostomy procedure; Percutaneous Endoscopy Gastrostomy tube 
placement; Critical care note; evaluation and management visit (Bile leak, Hyperbilirubinemia); and evaluation 
and management visit (Trauma Progress Note). Our reviewer found that both evaluation and management visits 
describe care for blunt trauma conditions. Our physician reviewer also found that an additional evaluation and 
management service for a separate distinct service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99231) provided on October 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Aer Ellipta. 
 
You asked the Plan to pre-approve Trelegy Aer Ellipta. The Plan denied your request. The Plan says Trelegy is 
a self-administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Aer Ellipta.  
 
Benefits for Trelegy Aer Ellipta may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient mental health visits provided on 
July 13, 2021, and September 16, 2021. 
 
You asked the Plan to waive the deductible for the outpatient mental health visits. You say that you thought 
your outpatient mental health visits would be covered through the 6 free counseling sessions through the 
Resources for Life benefit. The Plan denied your request. The Plan says the copayments applied were correct. 
 
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 $35 copayment for each in-person outpatient mental health visit after 
the deductible has been met.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
mental health care." The Plan has followed Medicare rules by clearly disclosing in the contract that the $750 
deductible applies to outpatient mental health care. This cost sharing is a contractual obligation that had not 
been met at the time the outpatient mental health visits were received on July 13, 2021, and September 16, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient mental health 
visits provided on July 13, 2021, and September 16, 2021.  
 Your complaint about the Resources for Life benefit is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services (00811) provided on November 16, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the claim is missing information. 
 
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. Specifically, the Plan has not forwarded any evidence to indicate what CPT code 
or revenue code is missing from the claim. Additionally, CPT code 00811 does not require a description on the 
claim as this is not a not otherwise classified code. It is the burden of the Health Plan to substantiate their 
denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the anesthesia services (00811) provided on November 16, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code G0482) provided on 
November 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code G0482 90 (1 
Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on November 12, 2021 and received by the lab on November 15, 2021. It is noted 
multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (CPT code G0482) provided on November 12, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) consultation provided on 
September 21, 2021, billed with code 99284. 
 
You asked the Plan to pay for the ED consultation. You say that there were two separate consultations, and 
both should be paid. The Plan denied your request. The Plan says these services were billed by the same billing group. As such, a modifier is required for the Column 2 code to explain why both visits should be paid to 
bypass the edit. 
 
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 the emergency department (ED) consultation provided on 
September 21, 2021, billed with code 99284.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the charge for additional supplies/services required due to 
COVID-19 during a visit on September 10, 2021. 
 
You asked the Plan to pay for the additional items/services as billed. You say that this claim should be paid due 
to medical necessity. The Plan denied your request. The Plan says code 99350 was paid according to the 
Medicare allowable. However, 99072 is not separately paid. 
 
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 items/services as billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the charge for additional supplies/services required due to COVID-19 during a visit on September 
10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
October 8, 2021, and October 13, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you thought there would 
be no out-of-pocket cost since the home health care you were receiving took the blood work. You say that you 
should not have to pay anything for the services. The Plan denied your request. The Plan says the copayments 
applied 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 $30 
copayment for lab services and diagnostic procedures/tests performed in an outpatient hospital facility.  
 
You have been asked to pay a total of $55.24 for the laboratory services.  
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
October 8, 2021 Lab Services $58.44 $30 $30 
October 13, 2021 Lab Services $25.24 $30 $25.24 
TOTAL:    $55.24 
 
The laboratory services 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 the laboratory services provided 
on October 8, 2021, and October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 
83550, and 84100) provided on October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The provider did not bill 
as required by Medicare coding regulations. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 82310, 82728, 83540, 83550, and 84100) provided on October 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (93306) provided on September 13, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ultrasound. You say that the enrollee did not inform you of their 
Medicare coverage, only their Medicaid coverage. Therefore, you did not know you were out-of-network at the 
time of services. The Plan denied your request. The Plan says out-of-network care is only covered in certain 
limited circumstances. The provider in this case is out-of-network; the services at issue were not urgent or 
emergent, nor were they pre-approved. 
 
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 ultrasound (93306) provided on September 13, 
2021, by an out-of-network (OON) provider.