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

 
We decided that the Plan does not have to reimburse you for the office visit (99213) provided on July 7, 2021. 
 
You asked the Plan to reimburse you for the office visit. You say that this should have been covered. You say 
that this is the first time you have had to submit a direct reimbursement. You also say that the provider advised 
they do not accept Medicare but can receive reimbursement. The Plan denied your request. The Plan says the 
services received are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. The file indicates that the provider in this case is a 
Naturopathic doctor. Therefore, we decided that the Plan does not have to reimburse you for the office visit 
(99213) provided on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 13, 
2021, to November 9, 2021. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service October 13, 2021, to November 9, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an ER visit provided on March 10, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you fell at a women's center and was 
informed you would not receive any bills regarding the incident. You say that the place of business was 
supposed to cover all charges and you did not give the hospital consent to file any claims to the Plan. The Plan 
denied your request. The Plan says that the copayment applied is correct. 
 
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 submit an Evidence of Coverage. This means that we cannot 
determine the cost you are being asked to pay is correct or justified by the Plan contract. Therefore, we decided 
that the Plan has to waive the copayment for an ER visit provided on March 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the testing was medically necessary, and 
you would like the claim reprocessed. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no approved authorization. Also, the service rendered was 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 the laboratory services provided on April 13, 
2022, 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 rendered on March 7, 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 procedure code 81479 is 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. 
 
In this case, the CPT Code Manual definition of code 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the specimen was not 
collected on the billed date of service. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on March 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nursing facility discharge day management services 
(99316) provided on February 22, 2022. 
 
You asked the Plan to pay for code 99316. 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 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. 
 
In this case, the CPT Code Manual definition of code 99316 is Nursing facility discharge day management; 
more than 30 minutes.  
We find that CPT code 99316 is not supported in the medical record. Specifically, there are no supporting 
records showing that more than 30 minutes of nursing facility discharge day management was provided on 
February 22, 2022. Based on this information, we decided that Medicare rules for coverage of code 99316 have 
not been met. Therefore, we decided that the Plan does not have to pay for the Nursing facility discharge day 
management services (99316) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 21, 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 supported. 
 
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 laboratory services provided on 
January 21, 2021, have been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on January 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) of the head. 
 
You asked the Plan to pre-approve an MRA of the head. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that all of the criteria listed in the Medicare rules section 
of this letter must apply in order for Medicare to provide coverage for MRA of the head and neck 
 
 
 
 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 an MRA of the head. Our reviewer says 
that an MRA of the head is not reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has headaches in the setting of lung cancer. The record provided does not document the 
presence for which coverage of the requested service is available. Our reviewer found that the elements of the 
coverage criteria are not satisfied. Our physician reviewer also found that the requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the head have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance angiography (MRA) of the head.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 25, 2022. 
 You asked the Plan to pay for the lab services. You say that the test identified possible treatment options. The 
Plan denied your request. The Plan says the unique test identifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the testing services were not billed as required. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing services provided on February 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on November 29, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that 
911 was called and you were transported to the emergency room due to being in severe, unrelenting bladder 
pain that became agonizing. The Plan denied your request. The Plan says the ambulance services are not a 
covered benefit. 
 
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 ambulance service, basic life support, 
non-emergency transport provided on November 29, 2021 have been met. The file does not contain medical 
records to determine if the ambulance transport was medically necessary. Therefore, we decided that the Plan 
does not have to pay for ambulance service, basic life support, non-emergency transport provided on 
November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on June 24, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit 
under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 12, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not supported for the enrollee's condition. 
 
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 the insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe 
and effective. 
 
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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on March 25, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, this code is not separately reimbursed when billed for specimen validity testing on 
specimens used for drug testing. In addition, the documentation does not support that this procedure was 
distinct or independent from other services performed. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan 
does not have to pay for the mass spectrometry and tandem mass spectrometry services coded 83789 provided 
on March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that you have provided medical records to 
support payment. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71250 is bundled into payment for code 71275. 
 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 71250 
is a column II code to column I code 71275. 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 71250 billed for date of service May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye refraction (92015) provided on May 9, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the first exam you received was a general eye 
exam which was the first step. You also say that the second exam was a specialist exam due to having cataracts 
and possibly glaucoma. The Plan denied your request. The Plan says that the refraction performed on this date 
of service denied accurately as your benefit maximum for the year had already been reached. 
 
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 provide a copy of the applicable 2022 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been 
adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pay for the eye refraction (92015) 
provided on May 9, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on May 27, 2022. 
 
You asked the Plan to pay for DME. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 did not pre-approve the 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for DME provided on May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 28, 2022, billed with 
codes 81292, 81294, 81295, 81297, 81298, 81300, 81317 and 81319. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 28, 2022, billed with codes 81292, 81294, 81295, 81297, 81298, 81300, 81317 and 81319.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on April 5, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 panel testing was not billed with a single code as required.  Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on April 5, 2022.