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

 
We decided that the Plan does not have to pre-approve office visits and radiologic exams (99204, 99214, 
72110) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and radiologic exams. You say that you are wearing a brace, 
using a walker and are in an incredible amount of pain. You need to be seen by the requested provider. The 
Plan denied your request. The Plan says you must use network providers to get your medical care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits and radiologic exams (99204, 99214, 72110) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 16, 2021 billed 
with codes 85097, 88112, 88184, 88377, 88368, 88342, 88341, 88313, 88311, 88305, 88291, 88264, 88237, 
88189, and 88185. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says multiple codes were billed for a single testing panel. 
 
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 
November 16, 2021 billed with codes 85097, 88112, 88184, 88377, 88368, 88342, 88341, 88313, 88311, 
88305, 88291, 88264, 88237, 88189, and 88185.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment planning and external beam radiation therapy 
(EBRT) provided on August 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for treatment planning and external beam radiation therapy (EBRT). You say that 
this is necessary and should be covered. The Plan denied your request. The Plan says this was an out-of-
network provider and facility. The plan requested you go to a different in-network facility, as the providers 
there have the same expertise. Therefore, this is upheld. 
 
 
 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 treatment planning and external beam radiation 
therapy (EBRT) provided on August 2, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that the records support that multiple procedures 
were rendered on this date. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exams (92012), gonioscopy (92020), and fundus 
photography with interpretation and report (92250) provided on February 17, 2022, and May 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exams, gonioscopy, and fundus photography with interpretation and 
report. You say that you were misled and told the treating provider was in-network when you signed up with 
this plan. You also say that you need help. The Plan denied your request. The Plan says your plan excludes 
coverage for these OON services. 
 
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 eye exams (92012), gonioscopy (92020), and 
fundus photography with interpretation and report (92250) provided on February 17, 2022, and May 19, 2022, 
by an out-of-network (OON) provider.  
 
Your complaint about being misled about the provider's network status 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on February 10, 2022, billed 
under code 88305. 
 
You asked the Plan to pay for the pathology services. You say that this should be paid due to medical necessity. 
The Plan denied your request. The Plan says the TC for this code cannot be paid as the enrollee was a hospital 
outpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that the TC of physician pathology services is not 
paid to the physician when provided to a hospital inpatient or outpatient. 
 
We looked at the file and Medicare rules. The Plan provided evidence showing that the sample at issue was 
taken in the outpatient hospital setting. As such, this code can only be paid with modifier -26. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided on February 10, 
2022, billed under code 88305.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator (E1390) 
purchased February 18, 2022. 
 
You asked the Plan to reimburse you for the oxygen equipment. You say that the information was sent with the 
doctor's order sheet. You were told by an agent that if you filled out some forms the Plan would pay a portion 
of the concentrator. The Plan denied your request. The Plan says this cost sharing was charged correctly. Per 
Medicare guidance, oxygen equipment is only covered when rented. Purchased oxygen equipment is excluded 
from coverage. 
 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 are responsible for 
paying the full cost of services that is not covered by the Plan, either because they are not Plan covered 
services, or Plan rules were not followed. 
 
You are asking for reimbursement for the purchased oxygen equipment. This item/service falls within the 
Durable Medical Equipment (DME) and Related Supplies benefit category. Medicare rules says that payment is 
not made for purchases of this type of equipment. 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 reimburse you for the 
portable oxygen concentrator (E1390) purchased February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy test provided May 31, 2021. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy test. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy test is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid 
biopsy test have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF 
liquid biopsy test provided May 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept service (A0999) provided on June 
18, 2022. 
 
You asked the Plan to pay for the paramedic intercept service. You say that you are unable to pay this bill. The 
Plan denied your request. The Plan says your coverage does not provide for this Ambulance service. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept service (A0999) provided on June 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services received on September 3, 2021, to 
September 8, 2021. 
 
You asked the Plan to pay for the hospital services. You say that your bill had to be paid upon discharge. The 
Plan denied your request. The Plan says medical records and proof of payment must be provided. 
 
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. Medical records were not provided 
to support that the services received while out of the country were medically necessary. Proof of payment and 
medical records are required for consideration of payment. Therefore, we decided that the Plan does not have to 
pay for the hospital services received on September 3, 2021, to September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 and 99292 provided on 
October 15, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
The CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the 
documentation does not include the time spent providing the critical care service. Therefore, code 99291 is not 
supported. In this case, we have confirmed that code 99292 is an add-on code. Since the primary procedure 
code 99291 was denied, this means that add-on code 99292 has not been billed with an appropriate primary 
procedure code. 
 
Based on this information, we decided that Medicare rules for coverage of the critical care services have not 
been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 
and 99292 provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479 and 81404) provided on April 
9, 2021. 
 
You asked the Plan to pay for procedure codes 81479 and 81404. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81479 and 81404) provided on April 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) modalities evaluation, re-
evaluations, electrical stem, manual therapy, and US therapy (97162, 97164, 97010, 97012, 97112/97035, 
97110, 97530, 97140, G0283) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT modalities evaluation, re-evaluations, electrical stem, manual therapy, 
and US therapy. You say that you disagree with the denial, and you do not want to drive 20 miles to receive 
treatment. The Plan denied your request. The Plan says you must use network providers to get your medical 
care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) modalities evaluation, re-evaluations, electrical stem, manual therapy, and US therapy 
(97162, 97164, 97010, 97012, 97112/97035, 97110, 97530, 97140, G0283) to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service March 24, 
2022, to March 27, 2022. 
 
You asked the Plan to pay for procedure code 80307. You say that this is a covered code which should be paid. 
The Plan denied your request. The Plan says medical records are necessary to process this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 80307 billed for date 
of service March 24, 2022, to March 27, 2022. have been met. Specifically, no medical records were provided to show that this service was medically necessary, reported correctly, and ordered by the enrollee's treating 
physician. Therefore, we decided that the Plan does not have to pay for procedure code 80307 billed for date of 
service March 24, 2022, to March 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on June 
9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that you would like this service to be 
re-evaluated. The Plan denied your request. The Plan says the POS benefit requires authorization prior to 
services and the provider is not contracted. The Plan also says that there is no referral from your primary care 
physician, and no evidence of a medical emergency. 
 
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. Although the enrollee's plan has a 
Point of Service (POS) benefit, authorization is still required to see any out of network providers. 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 wheelchair van transportation (A0130) provided on June 9, 2022, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of a new patient (99203) provided on June 16, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee had multiple 
days in hospital. You also say that they were seen by different specialties under the same tax identification 
number. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A detailed history; A detailed 
examination; Medical decision making of low complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. 
Typically, 30 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the documentation submitted 
indicates that this enrollee previously received professional services from a physician with the same specialty 
and billing group. Based on this information, we decided that Medicare rules for coverage of the evaluation and 
management service have not been met. Therefore, we decided that the Plan does not have to pay for the office 
or other outpatient visit for the evaluation and management of a new patient (99203) provided on June 16, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 83789. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 83789 have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for procedure code 83789 billed for date of service June 6, 2022.