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

 
We decided that the Plan does not have to pay for the postoperative follow up visit (99024) provided on 
September 22, 2021. 
 
You asked the Plan to pay for the postoperative follow up visit. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says no separate payment is 
made for this 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 find that CPT code 99024 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99024 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the postoperative follow up visit have not been met. Therefore, we decided that the Plan does not have to 
pay for the postoperative follow up visit (99024) provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 9, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 provided on November 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 1, 2022, to January 4, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no daily skilled nursing or therapist needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
enrollee no longer qualified for SNF coverage during this time period. There is no evidence that the enrollee 
required or received skilled nursing or skilled therapy services during this time period. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from January 1, 2022, to January 
4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the review shows that the codes were not billed with 
modifier 26 per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hospital observation services (G0378-GZ) provided from 
December 24, 2021, to December 27, 2021. 
 
You asked the Plan to pay for code G0378-GZ. 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 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. Medicare rules also say that items and services 
that are not medically necessary are not covered. Medicare rules state that items submitted with a GZ modifier 
shall be denied automatically and will not be subject to complex medical review. 
 
We find that CPT code G0378 is not supported in the medical record. Specifically, this service was reported 
twice on two claim lines, and the second line includes the GZ modifier, which by definition means that these 
services do not meet the criteria for Medicare coverage. Based on this information, we decided that Medicare 
rules for coverage of hospital observation care have not been met. Therefore, we decided that the Plan does not 
have to pay for the Hospital observation services (G0378-GZ) provided from December 24, 2021, to December 
27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 20, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on January 6, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
 The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (83789-59) provided on January 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 3, 2022, to January 28, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 denied payment for the home health services because the dates of 
service were out of order on the claim submitted. However, the Plan provided no supporting evidence showing 
that the services are not payable as billed. Therefore, we decided that the Plan has to pay for the home health 
services provided from January 3, 2022, to January 28, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on June 7, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation submitted did not 
support the critical care services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
support that between 30-74 minutes of critical care were rendered based on the medical records that were 
provided. 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 
(99291) provided on June 7, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology tissue exam (88305) provided on September 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology tissue exam. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says prior authorization was not obtained 
for these services rendered by an OON provider. 
 
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 pathology tissue exam (88305) provided on 
September 8, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novoseven RT. 
 
You asked the Plan to pre-approve Novoseven RT. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 Novoseven RT. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found without an FDA-approved indication or 
reasonable exception provided to justify this medication, the Novoseven RT will be considered not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Novoseven RT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Novoseven RT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 28, 2021, 
through November 26, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been met 
for the home health services billed. 
 
 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 home health services provided 
from October 28, 2021, through November 26, 2021, have been met. In this case, no medical records were 
submitted to corroborate the services that were billed.  Therefore, we decided that the Plan does not have to pay 
for the home health services provided from October 28, 2021, through November 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Ophthalmologist visit provided on 
January 21, 2022. 
 
You asked the Plan to waive the copayment for the Ophthalmologist visit. You say that you feel you should not 
be responsible for this cost share amount, and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received an eye exam with an Ophthalmologist on the date of service at 
issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $30 
copayment for exams to diagnosis and treat diseases and conditions of the eye by an Ophthalmologist. 
 
We looked at the file, the Plan's contract, and Medicare rules. The file shows that you had an eye exam 
provided by an Ophthalmologist on January 21, 2022. You have been asked to pay a $30 copayment for the 
Ophthalmologist visit. The Ophthalmologist visit falls within the Vision Care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the Ophthalmologist visit provided on January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies (A4215, A4557) provided to the enrollee on 
November 5, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that codes A4215 and A4557 are not supported in the medical record. Specifically, it is not appropriate 
to report these codes separately. 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 supplies (A4215, 
A4557) provided to the enrollee on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing services provided on November 17, 
2021. 
 
You asked the Plan to pay for the CxBladder testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this testing is not covered 
as it was done for screening purposes. 
 
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 CxBladder testing services 
provided on November 17, 2021, have been met. In this case, no medical records have been provided from the 
enrollees provider indicating why the testing was ordered. Without medical records from the enrollees 
provider, it is not clear if the testing was medically reasonable and necessary. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing services provided on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies (A4220) provided to the enrollee on December 1, 
2021. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says payment for this service is always bundled into payment for other services not specified. 
 
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 find that procedure code A4220 is not supported in the medical record. Specifically, this code has a status 
indicator of "P" which means that it cannot be paid separately, and is always bundled into payment for other 
services. Based on this information, we decided that Medicare rules for coverage of the supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for supplies (A4220) provided to the enrollee on 
December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested genicular nerve block treatment 
is considered investigational and not medically necessary for the treatment of chronic knee pain. 
 
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 genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered an experimental/investigational procedure as its role in the 
management of knee osteoarthritis is not settled. The request is deemed as not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on July 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the QS modifier is appended to monitored anesthesia 
care services. 
 
We looked at the file and Medicare rules. The file shows that procedure code 00410 was incorrectly billed with 
the -QS modifier. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered 
on July 14, 2021.