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

 
We decided that the Plan does not have to pay for laboratory services (81401, 81194, 81295, 81317, 81309, 
81206, 81275, 81235, 81292, 81301, 81210, 81276, 81298) provided on September 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the provider regarded this test as a medically 
necessary and valuable tool when determining treatment for the patient. You also say that the industry standard 
for emergency and urgently needed services is applicable to coverage determination and therefore should be 
considered in the review of this claim. The Plan denied your request. The Plan says this provider is a non-
network provider who does not work with the Plan, and the member was referred by a provider who also does 
not work with the Plan.  The Plan also says that the member's primary care physician did not refer for services, and no medical necessity 
for an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 (81401, 81194, 81295, 81317, 
81309, 81206, 81275, 81235, 81292, 81301, 81210, 81276, 81298) provided on September 9, 2021, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on June 
10, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound of the heart. You say that the benefit summary 
makes it unclear on overall coverage versus services applied towards the deductible. You say that given your 
family history this test should be treated as preventive. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to radiological diagnostic service, 
including ultrasounds.  
 
 
 
 
 The records show the ultrasound was diagnostic in nature, not preventive. The item or service you asked the 
Plan to waive the copayment for falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to radiological diagnostic services, including ultrasounds. This cost sharing 
is a contractual obligation that had not been met at the time an ultrasound of the heart was received on June 10, 
2021. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound of the heart 
provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on November 23, 2021. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions 
are only covered by your Plan if performed by a participating vision provider and performed as a routine 
screening. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
 We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the audiometry threshold evaluation, the 
tympanometry measurement, and the office visit you had with an audiologist on August 2, 2021. 
 
You asked the Plan to waive the deductible for the audiology services. You say that the Plan did not pay 
anything for these services so you would like the claim adjusted. The Plan denied your request. The Plan says 
the services you received applied to the deductible.  The Plan says that you had not yet met your deductible at 
the time of these services. 
 
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 $500 deductible which applies to hearing services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which 
applies to hearing services. This cost sharing is a contractual obligation that had not been met at the time the 
audiology services was received on August 2, 2021. Therefore, we decided that the Plan does not have to waive 
the deductible for the audiometry threshold evaluation, the tympanometry measurement, and the office visit 
you had with an audiologist on August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fourth chest x-ray (procedure code 71045) provided to the 
enrollee on October 17, 2021. 
 
You asked the Plan to pay for the additional x-ray. You say that this was medically necessary. The Plan denied 
your request. The Plan says there is no documentation to support a fourth chest x-ray for this date 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. 
 
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 additional x-ray. Our reviewer says that the fourth x-ray 
is not supported in the medical records. Our reviewer found a review of the records showed three different 
chest x-rays done on 10/17/21, at 8:31, 1:40, and 5:15pm. A fourth exam was not documented. 
 
 
 
 
 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 additional x-ray have not been met. Therefore, we decided that the Plan 
does not have to pay for a fourth chest x-ray (procedure code 71045) provided to the enrollee on October 17, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy evaluation (97161) provided on July 28, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a physical therapy evaluation. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says based on the provided information, the Plan determined 
that they would maintain their original decision to not pay physical therapy services based on Chapter 3 of the 
2021 EOC. 
 
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 a physical therapy evaluation (97161) provided on 
July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance transportation services 
provided on October 12, 2021. 
 
You asked the Plan to waive the coinsurance for the ambulance transportation. You say that you went to the ER 
and there were no beds available. You say that this caused you to be transported to another facility. 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 40% 
coinsurance for each one-way ambulance trip from an out-of-network (OON) provider. 
 
 Service Allowed Amount 40% Coinsurance 
Basic Life Support (A0428) $227.46 $90.98 
Ground Mileage (A0425) $30.52 $12.21 
Total:  $103.19 
 
You have been asked to pay $103.19, which is 40% of the allowed amount for the ambulance transportation. 
The ambulance transportation falls within the Ambulance 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 coinsurance for ambulance transportation services provided on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 9, 2021. 
 
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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the member's face-to-face service was rendered in a laboratory setting.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99214), the trimming of dystrophic 
nails (G0127) and the debridement of nails (11720) provided on July 22, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a specialist office visit, the trimming of dystrophic nails and the debridement of 
nails. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. The Plan also says that it was determined that the services were not urgent or emergent. 
 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 a specialist office visit (99214), the trimming of 
dystrophic nails (G0127) and the debridement of nails (11720) provided on July 22, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code G0483) provided on May 
11, 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 supported by the records. 
 
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 G0483 90 
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; 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 G0483) provided on May 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology evaluation (88713) and tissue exam by a 
pathologist (88305) provided on May 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this service is not the responsibility of 
hospice as the specimen was collected prior to the enrollee's hospice election. The Plan denied your request. 
The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. 
The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the cytopathology evaluation (88713) and tissue exam by a 
pathologist (88305) provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 16, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says payment for this code is bundled 
into payment for 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 July 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on September 20, 
2021. 
 
You asked the Plan to pay for physical therapy services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional 
services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct 
supervision of auxiliary personnel.  We looked at the file and Medicare rules. The services at issue were billed as incident to the services a of nurse 
practitioner, but the records do not indicate the nurse practitioner was present at the time of service to provider 
direct supervision. Based on this information, we decided that Medicare rules for coverage of physical therapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy 
services (97110) provided on September 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation provided from July 19, 2021, to July 21, 2021, 
by wheelchair van. 
 
You asked the Plan to pay for transport by wheelchair van. You say that these transports were medically 
necessary. The Plan denied your request. The Plan says transport by wheelchair van is not covered by the Plan 
or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pay for transportation provided from July 19, 2021, to July 21, 2021, by 
wheelchair van.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot for the enrollee. 
 
You asked the Plan to pre-approve Lupron Depot. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not have any stated contraindications to the preferred 
products. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lupron Depot. Our reviewer says that 
Lupron Depot is not medically reasonable and necessary. The patient has not tried and failed Eligard. The 
plan's required drug is not likely to be less effective and/or likely have adverse effects for the enrollee. Our 
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Lupron Depot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says criteria 
for admission to the LTACH have not been met. The Plan also says that the enrollees medical needs are being 
met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available where 
she is currently receiving care. The enrollee is receiving appropriate care at the present 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this patient's clinical condition meets full inpatient 
rehab criteria, and the lower level of skilled nursing cannot provide the total approach necessary. The Plan 
denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary 
approach to daily therapy. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology examination of tissue using a microscope, 
intermediate complexity (CPT code 88305) provided on April 5, 2021. 
 
You asked the Plan to pay for the service. You say that the place of service billed is correct. The Plan denied 
your request. The Plan says the service is not covered 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. 
 
Review of the file shows that the member was an outpatient on this date of service and that the facility rendered 
procedure 88305 on the date of service April 05, 2021. Furthermore, we show another provider rendered 
service code 88305 on the same date of service and place of service 22 - Outpatient Hospital. Per the above 
Medicare guidelines, the plan is upholding the denial as the billed procedure code 88305 has a physician Fee 
Schedule PCTC indicator of 1. If the provider determines that a billing error occurred during the initial 
submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for 
payment. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the pathology examination of tissue using a 
microscope, intermediate complexity (CPT code 88305) provided on April 5, 2021.