Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fundus photography (92250), a visual field examination 
(92081), and a medical eye examination (92004) provided on May 2, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for fundus photography (92250), a visual field examination (92081), and a medical 
eye examination (92004). You say that you moved to a different state and were not aware that you did not have 
out-of-network coverage. The Plan denied your request. The Plan says you have a plan that does not cover non-
participating providers. The Plan also says that this service is covered 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 fundus photography (92250), a visual field 
examination (92081), and a medical eye examination (92004) provided on May 2, 2022, by an out-of-network 
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosing solution. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is status post numerous endovenous procedures including bilateral great 
saphenous vein ablation, bilateral small saphenous vein ablation and right anterior accessory saphenous 
ablation. The enrollee was re-evaluated six weeks following the last of these procedures and was noted to have 
improvement in symptoms with mild aching, heaviness, swelling, and throbbing of the medial calves 
bilaterally. As the symptoms are described as mild it is not clear that they are inhibiting mobility and it is not 
clear that the patient is experiencing significant symptoms despite the use of compression stockings. Coverage 
criteria require that the patient have residual symptoms that impaired mobility despite three months of 
conservative therapy. 
 
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 pre-approve injection of sclerosing solution.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 24, 2022, to May 
23, 2022. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted with the claim. 
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 home health services rendered on April 24, 
2022, to May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 28, 2022, billed with 
code 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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. Review of the file shows that codes 87798, 87150, 87481, 87500, 87640, 87651, and 87653 were 
also billed on the claim. 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 June 28, 2022, billed with code 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on July 5, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 64445: 
 
Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve 
 
CPT 64447: 
 
Injection(s), anesthetic agent(s) and/or steroid; femoral nerve 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee had general anesthesia with a laryngeal mask airway (LMA).  The anesthesia time documented was 16:43 - 19:05.  The 
enrollee was also documented to have a left popliteal/saphenous block. According to the guidelines, under 
certain circumstances, an anesthesia practitioner may separately report an epidural or peripheral nerve block 
injection for postoperative pain management when the surgeon requests assistance with postoperative pain 
management. The surgical operating room procedure note was reviewed along with the anesthesiology records 
and other medical records submitted.  The submitted documentation contained the nerve block note, however, 
did not indicate that the blocks were performed for postoperative pain management.  There was no 
documentation of the surgeon's request for popliteal/ saphenous nerve blocks for the patient's postoperative 
analgesia. The submitted documentation does not include the surgeon's request for post-operative pain 
management.  Therefore, CPT 64445-59-LT and CPT 64447-59-LT are not supported in the submitted 
documentation. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator provided on August 5, 
2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim was not submitted timely. 
 
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 automatic external defibrillator was not filed until August 19, 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 automatic external defibrillator provided on 
August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation (HFCWO) 
device. 
 
You asked the Plan to pre-approve a HFCWO device. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that HFCWO devices are covered when specific criteria 
are met. 
 
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 a HFCWO device. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a HFCWO is not medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD). There is no diagnosis of cystic 
fibrosis, bronchiectasis, or neuromuscular disease affecting diaphragm function. There is insufficient evidence 
that HFCWO is of benefit in COPD, and Medicare does not cover it for that diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWO device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high frequency chest wall oscillation (HFCWO) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that you respectfully disagree with this denial. The Plan 
denied your request. The Plan says there is no associated record detailing in-person fitting and training for use 
of the E0651 that was prescribed on June 15, 2022. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided medical records only document edema extending onto the abdomen on one occasion on 
07/27/2022 after use of the basic pump. Provided records are not clear as to whether this abdominal swelling 
was observed on physical examination by the medical provider or if this is historical information obtained from 
patient report; no measurements of the abdomen are documented. Other records only report lower extremity 
edema. The provided records do not clearly document at least four weeks of regular, daily, multiple-hour home 
usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided as required by the rules. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mindfulness-based cognitive 8-week program provided 
from January 18, 2022, to March 8, 2022. 
 
You asked the Plan to pay for the Mindfulness-based cognitive 8-week program. You say that you purchased a 
pain management program through your local hospital in 2021, and reimbursement was approved under the 
same program. You would like the Mindfulness-based cognitive 8-week program you purchased this year to be 
covered. The Plan denied your request. The Plan says this program is not covered under your Health and 
Wellness education benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may offer Health and Wellness education 
services as a supplemental benefit.  Because these services are not Medicare-covered services, it means that the 
Plan's coverage rules apply. In this case, your Plan only covers certain services under your Health and Wellness education benefit. The Mindfulness-based cognitive 8-week program you purchased is not listed under this 
benefit as a covered service, so it is not reimbursable.  This is true even if similar programs were reimbursed in 
the past.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Mindfulness-based cognitive 8-week program have not been met. Therefore, we decided that 
the Plan does not have to pay for the Mindfulness-based cognitive 8-week program provided from January 18, 
2022, to March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99202) provided on May 6, 
2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not covered under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to issue reimbursement for the office visit (99202) provided on May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for tangential biopsy of skin provided on June 
15, 2022. 
 
You asked the Plan to waive the copayment for tangential biopsy of skin. You say that you are disputing the 
cost share. 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 $350 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $225.41, which is less than the $350 copayment for tangential biopsy of skin. This 
item/service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 tangential 
biopsy of skin provided on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 7, 2022, billed with codes 81230, 81231, 81232, 81306, 81328, 81335, 81355, 0031U, 0032U, and 0033U.

You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.

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 May 7, 2022, billed with codes 81230, 81231, 81232, 81306, 81328, 81335, 81355, 0031U, 0032U, and 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on June 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the 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 nursing facility visit provided on June 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on October 11, 2021. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and was reported correctly. 
The Plan denied your request. The Plan says that the records provided do not support this service as billed, as 
the records show that only nine classes were tested. 
 
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 G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers, 15-21 drug class(es), including metabolite(s), if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record supports that fifteen 
or more drug classes were tested in this panel, including amphetamines, barbiturates, benzodiazepines, cocaine, 
fenanyls, gabapentin (non-blood), heroin metabolite, methadone, methylphenidate, opiates, opioids and opiate 
analogs, oxycodone, pregabalin, sedative hypnotics (non-benzodiazepines) and tramadol. Based on this 
information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided 
that the Plan has to pay for definitive drug testing (G0482) provided on October 11, 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 procedure codes 88361, 88312, 8835 and 88112 billed for 
date of service March 7, 2022. 
 
You asked the Plan to pay for procedure codes 88361, 88312, 8835 and 88112. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
services were not reported in accordance with Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88361, 88312, 8835 and 88112 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88361, 88312, 8835 and 88112 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88361, 88312, 8835 and 88112 billed for date of service March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture and infrared therapy services rendered on 
January 3, 2022. 
 
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 the services are not covered.  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that the services were performed by 
auxiliary personnel without the supervision of a physician, PA, or NP/CNS. Therefore, we decided that the 
Plan does not have to pay for the acupuncture and infrared therapy services rendered on January 3, 2022.