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

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the records provided support the need 
for the requested services. The Plan denied your request. The Plan says the enrollee does not have a history of 
coronary artery disease. The Plan says that the records do not show that it is medically reasonable to pursue 
cardiac catheterization at this time in the work-up of the enrollee's problems, without other less invasive cardiac 
testing and evaluation first. 
 
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 left heart catheterization. Our reviewer 
says that left heart catheterization is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records provided do not support the rationale for this invasive imaging 
study. The enrollee has had no recent non-invasive stress testing performed. Guidelines do not support a need 
for cardiac catheterization in this 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 26, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing and have submitted clinicals 
to show medical necessity and request a reconsideration of the denied charges. The Plan denied your request. 
The Plan says the out-of-network services were not authorized. 
 
 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 provided on April 26, 2022, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) provided on April 23, 2022. 
 
You asked the Plan to pay for the frames. You say that you contacted the Plan to verify your eligibility and 
were told you have $300. The Plan denied your request. The Plan says your benefit maximum has been met. 
The Plan also says that no misinformation was provided during your call to the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglass frames or contact lenses every year. 
 
We looked at the file and the Plan's rules. The record shows that you last received frames on May 8, 2021, and 
your eyeglass frames benefit has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the frames have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames (V2020) provided on April 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing provided on February 8, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that Medicare now provider coverage for this testing. 
The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder test code 0013M is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. This test code is not covered by Medicare. Based on this information, 
we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided 
that the Plan does not have to pay for CxBladder testing provided on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided March 
19, 2022. 
 
You asked the Plan to pay for the diagnostic service. You say that this claim denied as duplicate in error. Please 
review and reprocess the claim for reimbursement according to contract. The Plan denied your request. The 
Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 29, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, chest (71045) 
provided March 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for feeding tube supplies/services provided from February 24, 
2022, to March 9, 2022. 
 
You asked the Plan to pay for feeding tube supplies/services. You say that the enrollee's hospice was 
terminated on February 14, 2022. The Plan denied your request. The Plan says original Medicare is responsible 
for payment.  
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 feeding tube supplies/services provided from February 24, 
2022, to March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recliner and chair lift purchased on January 22, 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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the recliner and chair lift 
purchased on January 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (19125) provided on March 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been 
exceeded. 
 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 19125 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 the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (19125) 
provided on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transport and set-up of portable x-ray equipment, an x-ray 
and an ECG provided on April 24, 2022, by an OON provider. 
 
You asked the Plan to pay for transport and set-up of portable x-ray equipment, an x-ray and an ECG. You say 
that the services were rendered to the enrollee in an assisted living facility. The Plan denied your request. The 
Plan says the out-of-network services were not authorized. 
 
 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 transport and set-up of portable x-ray equipment, 
an x-ray and an ECG provided on April 24, 2022, by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for molecular testing services (81479) billed for date of service, November 
1, 2021. 
 
You asked the Plan to pay for molecular testing. You say that these services were medically necessary and are 
supported as billed. The Plan denied your request. The Plan says that the specimen for this laboratory testing 
was collected on December 12, 2019; this is the date which should be billed as the date of service for this 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be billed 
with the date the specimen was collected as the date of service. However, there are three exceptions to this rule.  
 
We looked at the file and Medicare rules. The record indicates that the sample in this case was taken on 
December 12, 2019. This test was a chemotherapy sensitivity test and/or a service performed on live tissue, and 
the sample was taken while the enrollee was in an outpatient hospital setting as part of an outpatient procedure. 
The results of this service/test did not guide treatment during that hospital stay, was medically necessary, and it 
would have been inappropriate to have collected this sample outside of this hospital procedure for which the 
enrollee was admitted. This means that an exception to the general rule has been met. When this specific 
exception is met, the date of service of this test/service must be the date the test/service was performed. This 
test was performed on November 1, 2021, following a physician order when it was found that there was a 
recurrence of the enrollees cancer. This means that this claim was submitted correctly. Based on this 
information, we decided that Medicare rules for coverage of molecular testing have been met. Therefore, we 
decided that the Plan has to pay for molecular testing services (81479) billed for date of service, November 1, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc injections (20610, 77002, J7320). 
 
You asked the Plan to pre-approve the Genvisc injections. You say that this service is medically necessary. The 
Plan denied your request. The Plan says Genvisc is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Genvisc injections. Our reviewer 
says that Genvisc is not medically necessary in this application. Our physician reviewer found medical 
literature states that viscosupplementation therapy is medically necessary for the treatment of osteoarthritis in 
the knee. This request is for hip pain. Use in this setting is considered investigational. More research is needed 
to show safety and efficacy. 
 
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 Genvisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Genvisc injections (20610, 77002, J7320).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90837) provided on April 27, 2022. 
 You asked the Plan to pay for psychotherapy. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no documentation that the enrollee would have benefited from this service. 
 
The Plan follows Medicare rules. Medicare rules say that psychotherapy will be considered medically 
necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms 
sufficient to cause inappropriate behavior or maladaptive functioning.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for psychotherapy. Our reviewer says that the 
psychotherapy was not medically necessary. Our physician reviewer found the records show that the enrollee 
was seen for a diagnostic evaluation follow-up, but the enrollee was not experiencing symptoms that warranted 
the visit for psychotherapy. The enrollee was described as having anxiety symptoms but no depressive 
symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not 
have to pay for psychotherapy (90837) provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electric seat lift mechanism and supplies provided on 
March 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an electric seat lift mechanism and supplies. You say that your physician sent 
prescription orders for this because of your disabilities. The Plan denied your request. The Plan says the items 
obtained by the member were purchased from a provider who is not under contract with the health plan and is 
not certified for Medicare. 
 
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 an electric seat lift mechanism and supplies 
provided on March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81286, 81413, 81414, 81442, 81161, 81479) 
provided on January 6, 2022. 
 
You asked the Plan to pay for genetic testing (81286, 81413, 81414, 81442, 81161, 81479). You say that the 
treatment sought is medically necessary to treat the patient based on the patient's medical condition. The Plan 
denied your request. The Plan says they were unable to discover any evidence of an established relationship 
between the member and the ordering physician. 
 The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests, and other diagnostic 
tests must be ordered by the physician who is treating the beneficiary and tests not ordered by the physician 
who is treating the beneficiary are not reasonable and necessary. While a physician order is not required to be 
signed, the physician must clearly document, in the medical record, the intent that the test be performed.  
 
We looked at the file and Medicare rules. There is no order or medical record showing an intent to order the 
tests billed on the claim, so it cannot be paid. Based on this information, we decided that Medicare rules for 
coverage of genetic testing (81286, 81413, 81414, 81442, 81161, 81479) have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic testing (81286, 81413, 81414, 81442, 81161, 81479) 
provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 14, 2021, by an 
OON provider. 
 
You asked the Plan to pay for laboratory services. You say to please review and reconsider coverage. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 
 
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 provided on December 14, 
2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI), abdomen (74181-
26), and 3D rendering with interpretation and report (76376-26) provided on March 4, 2022. 
 
You asked the Plan to pay for the imaging services. You say that the records support that this procedure was 
performed by the provider. You also say that this claim denied as a duplicate in error. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the imaging services at issue were 
reimbursed by the Plan on April 1, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed imaging services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI), abdomen 
(74181-26), and 3D rendering with interpretation and report (76376-26) provided on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurology office visits to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services the 
enrollee needs. 
 
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 
the neurology office visits to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on November 8, 2021, by an OON 
provider. 
 
You asked the Plan to pay for a drug test. You say that you are appealing the claim payment denial for services 
rendered to our member. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 drug test provided on November 8, 2021, by an 
OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 24, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 24, 2022.