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

 
We decided that the Plan does not have to reimburse for the dental services provided from April 11, 2022, 
through May 3, 2022. 
 
You asked the Plan to reimburse for the dental services. You say that you are requesting reimbursement for 
dental services you received while you were in Spain. The Plan denied your request. The Plan says information 
was not provided to verify services were received. 
 
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 the 
dental services have been met. Medical records and evidence of payment were not provided to verify if the 
services were necessary or that they were received. Therefore, we decided that the Plan does not have to 
reimburse for the dental services provided from April 11, 2022, through May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99245 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 99245. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99245 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99245 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99245 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99245 billed for date of service October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72080 billed for date of service November 4, 
2022. 
 You asked the Plan to pay for procedure code 72080. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 72080 is bundled into payment for code 
72070. 
 
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 72080 
is a column II code to column I code 72070. 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 72080 billed for date of service November 4, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service July 29, 
2022. 
 You asked the Plan to pay for procedure code 12002. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 12002 is bundled into payment for code 26750. 
 
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 12002 
is a column II code to column I code 26750. 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 12002 billed for date of service July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83550 billed for date of service January 18, 
2022. 
 
You asked the Plan to pay for procedure code 83550. The Plan denied your request. The Plan says payment for 
code 83550 is bundled into payment for code 84466. 
 
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 83550 
is a column II code to column I code 84466 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 83550 billed for date of service January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on August 30, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets.  
 
We looked at the file and Medicare rules. In this case, the requested respiratory pathogen panel was billed with 
multiple codes and multiple units of service. Per A57588, a respiratory pathogen panel should only be billed 
with one unit of service. Based on this information, we decided that Medicare rules for coverage of the panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel 
provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis provided on September 12, 2022. 
 
You asked the Plan to pay for the wrist hand orthosis. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says Medicare rules say that certain elements are required on the claim 
submission. 
 
The Plan must follow Medicare rules. Medicare rules say that an NPI must be submitted on the claim. 
 
We looked at the file and Medicare rules. Review of the file shows that an incorrect NPI number was submitted 
on the claim. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis 
have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis 
provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reprocess the claims for the massage therapy (97124) provided from 
February 3, 2022, through November 15, 2022. 
 
You asked the Plan to reprocess the claims for these services. You say that you are requesting that the claims 
be reprocessed at the therapeutic massage benefit. The Plan denied your request. The Plan says the claims were 
processed correctly, based on the credentialed status of the rendering provider. 
 
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 Plan contract provides supplemental coverage 
for chiropractic services for manipulations considered maintenance therapy or to maintain alignment.  
 
The record shows that the claims for the services provided were processed at the allowable chiropractic benefit 
as the services at issue were rendered by a chiropractor.  The Plan contract states that therapeutic massage must be provided by a licensed massage therapist. Therefore, 
we decided that the Plan does not have to reprocess the claims for the massage therapy (97124) provided from 
February 3, 2022, through November 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 10, 2022 to 
April 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 10, 2022 to April 
8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service November 7, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the member had multiple exams done on 
this date of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service November 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw 
(CPT 70100), radiologic examination, teeth; partial examination, less than full mouth (CPT 70310), a 
radiologic examination, chest; single view (CPT 71045), a radiologic examination, upper gastrointestinal tract, 
including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (e.g., barium) 
study) (CPT 74240), and a complete barium swallow study (CPT 74230) provided on October 3, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), radiologic 
examination, teeth; partial examination, less than full mouth (CPT 70310), a radiologic examination, chest; 
single view (CPT 71045), a radiologic examination, upper gastrointestinal tract, including scout abdominal 
radiograph(s) and delayed image(s), when performed; single contrast (e.g., barium) study) (CPT 74240), and a 
complete barium swallow study (CPT 74230). You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided at an excluded place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that that procedures and examinations which are not 
covered under the portable x-ray provision include procedures requiring the administration of a substance to the 
patient or injection of a substance into the patient and/or special manipulation of the patient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), radiologic examination, teeth; 
partial examination, less than full mouth (CPT 70310), a radiologic examination, chest; single view  
(CPT 71045), a radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) 
and delayed image(s), when performed; single contrast (e.g., barium) study) (CPT 74240), and a complete 
barium swallow study (CPT 74230) have not been met. Therefore, we decided that the Plan does not have to 
pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), radiologic examination, teeth; partial 
examination, less than full mouth (CPT 70310), a radiologic examination, chest; single view (CPT 71045), a 
radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed 
image(s), when performed; single contrast (e.g., barium) study) (CPT 74240), and a complete barium swallow 
study (CPT 74230) provided on October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory viral testing panels (0202U) provided October 10, 
2022. 
 
You asked the Plan to pay for the respiratory viral testing panel. You say that this should be covered because 
you went in at nighttime and your doctor recommended this procedure. The Plan denied your request. The Plan 
says PCR respiratory viral panels of 6 or more pathogens are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory viral testing panel have not been met. Therefore, we decided that the Plan does not 
have to pay for respiratory viral testing panels (0202U) provided October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service September 
15, 2022 to September 29, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 97010 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service September 15, 2022 to September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve the physician's services to be provided by the requested out-of-network 
provider. You say that you had been seeing this provider before and you want to continue seeing this provider. 
The Plan denied your request. The Plan says out-of-network services are not medically necessary at this time. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says the enrollee has been debilitated since December of 2022, and it is unlikely 
the enrollee would improve a lot in a reasonable amount of time. 
 
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 enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a pneumatic compression device (PCD) (E0652) and full 
leg garments (E0667). 
 
You asked the Plan pre-approve a pneumatic compression device. You say that the items should be covered. 
The Plan denied your request. The Plan says there is no documentation of edema extending to the chest, trunk 
or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have pre-approve a pneumatic compression device (PCD) (E0652) and full leg garments (E0667).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient surgery provided on September 12, 2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that the service should be covered. The Plan 
denied your request. The Plan says that the claim was denied for principal diagnosis inappropriately coded. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan did not include the claim or any other information about what was 
billed. Therefore, we decided that the Plan has to pay for the outpatient surgery provided on September 12, 
2022.  
 
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.