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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 6, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service February 6, 
2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81206) provided on November 27, 2021. 
 
You asked the Plan to pay for code 81206. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for code 81206 by a contract provider. The file does not show that the plan provided 
notice that code 81206 would not be covered. Under Medicare rules, this means code 81206 is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services (81206) 
provided on November 27, 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 a Hereditary Cardio Screen 177 Gene Panel provided to the 
enrollee on September 29, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this denial is appropriate given the clinical scenario. 
 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. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no Medicare benefit for screening cardiovascular risk assessment testing for asymptomatic 
patients. Screening asymptomatic patients for cardiovascular risk is statutorily excluded by Medicare. The 
review has determined that the services at issue in this case are not medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a Hereditary Cardio Screen 177 Gene Panel provided to the enrollee on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride treatment, excluding varnish (D1208), and 
bitewing x-rays (D0274) provided on October 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dentist determined that you did not need a 
full mouth x-ray. You say that ordering a full mouth x-ray would expose you unnecessarily to excessive 
radiation. You also say that these services should be covered. The Plan denied your request. The Plan says 
fluoride, excluding varnish, is covered once per year. The Plan says the frequency limit has been exceeded. The 
Plan also says that bitewing x-ray is not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage and fluoride, excluding varnish, is 
covered once per year, the frequency limit has been exceeded. The record shows that the Plan paid for fluoride 
treatment that you received on April 16, 2021. Additionally, the bitewing x-ray is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the fluoride treatment, 
excluding varnish (D1208), and bitewing x-rays (D0274) provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95861-TC, 95865-TC, 95927-TC, 
95937-TC, 95938-TC, 95939-TC) provided on March 23, 2021. 
 
You asked the Plan to pay for neuromonitoring services. You say that this was billed correctly. The Plan denied 
your request. The Plan says this was not billed with a payable modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Hospital bundling rules exclude payment 
to suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient at the time of 
service, but the services at issue were billed with the TC modifier. The TC is not payable. Based on this 
information, we decided that Medicare rules for coverage of neuromonitoring services have not been met. 
Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95861-TC, 95865-TC, 
95927-TC, 95937-TC, 95938-TC, 95939-TC) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on September 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that the code is appropriately identified as a 
separate procedure. The Plan denied your request. The Plan says there are no modifiers allowed with this code 
pair. 
 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 99156 is moderate sedation services provided by a 
physician or other qualified health care professional other than the physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of 
intraservice time, patient age 5 years or older. 
 
The file shows that CPT code 99156 was billed with CPT code 27265. We find that there is a correct coding 
modifier indicator of 0. This means that CPT code 99156 is not eligible for payment. 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 anesthesia services provided on September 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 81000, 82306, 82465, 83036 
and 85025) provided on June 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct POS 
code. 
 
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 laboratory 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 laboratory services (80053, 81000, 82306, 82465, 83036 and 85025) 
provided on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genicular nerve branch destruction (64624) provided on July 
15, 2021. 
 
You asked the Plan to pay for genicular nerve branch destruction. You say that this is a covered service. The 
Plan denied your request. The Plan says this is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that overage for code 64624 is limited to specific 
diagnosis codes.  
 
We looked at the file and Medicare rules. The billed diagnosis M17.12, unilateral primary osteoarthritis, left 
knee, is not listed as providing coverage for the service at issue. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve branch destruction have not been met. Therefore, we decided 
that the Plan does not have to pay for genicular nerve branch destruction (64624) provided on July 15, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the respiratory pathogen panel (0241U) provided on November 18, 
2021. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says that this service was not rendered 
in the appropriate place of 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, the CPT Code Manual definition of code 0241U is infectious disease (viral respiratory tract 
infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], 
influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen 
reported as detected or not detected. 
 
We find that CPT code 0241U is supported in the record. Specifically, the governing LCD does not include any 
information to bar the critical access hospital from proving and billing for this testing. The Plan has not 
forwarded any additional evidence to substantiate their denial. It is the burden of the Health Plan to substantiate 
their denial with evidence so we must find in your favor. Based on this information, we decided that Medicare 
rules for coverage of the respiratory pathogen panel have been met. Therefore, we decided that the Plan has to 
pay for the respiratory pathogen panel (0241U) provided on November 18, 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 knee strapping (29530) and infrared therapy (97016) 
provided on September 20, 2021. 
 
You asked the Plan to pay for the knee strapping and infrared therapy. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says infrared therapy is 
not covered, and CPT 29530 has an edit with 20611. 
 
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 rules also say that there is sufficient 
evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and 
necessary. 
 
In this case, we have confirmed that code 29530 is a column II code to column I code 20611. This claim has 
not been billed with an appropriate modifier to bypass the edit. Additionally, per NCD guidelines, infrared 
therapy is considered not reasonable and necessary. 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 knee strapping (29530) and 
infrared therapy (97016) provided on September 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on August 28, 2021. 
 
You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 subsequent hospital care provided on August 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85025, 36415, 80053, 80061, 81003, 
84403, 84443) provided on November 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the physician reached this treatment 
determination based on professional medical judgement and all the circumstances related to the member's 
condition. The Plan denied your request. The Plan says this provider is not a network provider with the Plan 
and the services were not referred by a network provider or rendered in an in-network facility. The Plan also 
says that they have also determined that these services are not urgent or emergent, nor were they approved in 
advance.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (85025, 36415, 80053, 80061, 
81003, 84403, 84443) provided on November 19, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee is not unsafe sitting in a wheelchair, does not have behaviors that require 
continuous monitoring, and is not a threat to self or others. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van) were 
contraindicated for this patient. The documentation does not support that the patient needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport. The patient was stable. The documentation does not support that the ambulance transport on  was 
medically reasonable and necessary for the patient. Based on the documentation provided, the patient did not 
appear to be unsafe if sitting in a wheelchair and was not at risk to self or others if transported via another 
vehicle.   
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 ambulance services provided to the enrollee on December 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
November 8, 2021, to December 10, 2021, and a knee x-ray provided on December 13, 2021. 
 
You asked the Plan to waive the copayments for an x-ray and physical therapy visits. You say that you were 
getting rehab for your knee after having surgery on November 4, 2021. 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 $45 
copayment for in-network x-rays.  The Plan contract also says that enrollees must pay a $40 copayment for in-network physical therapy visits. 
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay the allowed amount of $41.17, which is less than the $45 copayment for an x-ray on December 13, 2021. 
An x-ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
You have been asked to pay a total of $480, which is a $40 copayment for each physical therapy visit from 
November 8, 2021, to December 10, 2021 ($40 copayment x 12 visits = $480). Physical therapy visits fall 
within the Outpatient Rehabilitation 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 copayments 
for physical therapy visits provided from November 8, 2021, to December 10, 2021, and a knee x-ray provided 
on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services provided on October 8, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code 
remains 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 95871 is needle electromyography; limited study of 
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, 
cranial nerve supplied muscles, or sphincters.  
 
We find that CPT code 95871 is not supported in the medical record. Specifically, there is a more 
comprehensive code billed to describe the services provided to the enrollee. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the needle electromyography services provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation services (D9222, D9223) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you needed to be put to sleep for the surgery. 
You say that your gum had to be cut. You also say that this should be covered. The Plan denied your request. 
The Plan says deep sedation services are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the deep sedation services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep 
sedation services (D9222, D9223) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for contact lenses provided on  
December 9, 2021. 
 
You asked the Plan to pay an additional amount for the contact lenses. The Plan denied your request. The Plan 
says the Plan paid $150 toward the contact lenses. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum vision hardware 
allowance. Therefore, we decided that the Plan does not have to pay an additional amount for contact lenses 
provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on June 29, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you did not know an authorization was 
needed and thought it was an emergency. The Plan denied your request. The Plan says the rendering provider is 
an out-of-network provider and there was no referral from an in-network provider or an 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 outpatient services provided on June 29, 2021, 
by an out-of-network (OON) provider.