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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87798, 87641, 88305 and 88312) provided 
on February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the lab services should be covered. The Plan 
denied your request. The Plan says these services are not covered because they were provided OON. 
 
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 lab services (87798, 87641, 88305 and 88312) 
provided on February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 31, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you never asked to have this procedure and feel 
you should not be held responsible. The Plan denied your request. The Plan says this service is not covered 
under your 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 these services when the refraction is performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of other age-related incipient cataract, bilateral. Based on this information, we decided that the Plan's 
rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for the eye refraction (92015) provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the power operated vehicle (scooter) 
provided on June 23, 2022. 
 
You asked the Plan to waive the coinsurance for the power operated vehicle (scooter). You say that you are on 
a fixed income and cannot afford the coinsurance. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the power operated vehicle (scooter). This item/service falls 
within the durable medical equipment (DME) and related supplies 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. The allowed amount for the scooter is $972.21, 
and the 20% coinsurance applied is $194.44. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the power operated vehicle (scooter) provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 99253. You say that the medical records support the services 
rendered. 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 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 99253 billed for date of service February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction provided by an out-of-network provider on April 1, 2022. 
 
 You asked the Plan to pay for the routine ophthalmological examination including refraction. You say that the 
enrollee was not informed that the provider was changed from a network provider to an out-of-network 
provider. This bill is a financial hardship for the enrollee. The Plan denied your request. The Plan says the 
provider was out-of-network. 
 
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 these services when the provider is in-network. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the routine ophthalmological examination 
including refraction have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
ophthalmological examination including refraction provided by an out-of-network provider on April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on June 03, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you went to 
this facility as you assumed it was a free-standing facility. You say that you feel you should have to pay the 
$150.00 instead of the $207.76. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $225 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay $207.76 which is less that the standard copayment for magnetic resonance imaging 
(MRI). This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 
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 magnetic resonance imaging 
(MRI) provided on June 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GeneSight pharmacogenomic (PGx) testing. 
 
You asked the Plan to pre-approve PGx testing. You say that this test is medically necessary. The Plan denied 
your request. The Plan says there is no documentation that the disorder currently being treated is unstable or 
that your provider is planning a medication change at this time. Therefore, the requested test is not medically 
necessary. 
 The Plan must follow Medicare rules. Medicare rules say that the clinical record must clearly show the use of 
or intent to prescribe a drug that has known drug-gene interactions that require a PGx test to be ordered to 
define the safe use of that drug in that patient. PGx testing is not covered when a treating clinician is not 
considering treatment with a medication that has an actionable drug-gene interaction, or when the use of a 
medication with a drug-gene interaction is not reasonable and necessary. In order for PGx testing to be covered, 
the patients medical record must clearly reflect certain information. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PGx testing have not been met. Specifically, the medical records provided do not indicate that the 
provider has any intention for this testing to be performed or that a change in the enrollees current medication 
is being considered. Therefore, we decided that the Plan does not have to pre-approve GeneSight 
pharmacogenomic (PGx) testing.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you disagree with the 
copayment amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $230 
copayment for Ambulance services. 
 
You have been asked to pay a $230 copayment for ambulance transport. This item/service falls within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for ambulance transport 
provided on February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal x-ray provided on May 26, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the procedure was rendered in an appropriate place of 
service. The Plan denied your request. The Plan says the claim was billed with an incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be submitted with the correct POS 
code. An inpatient POS code must be used when the service is rendered to an enrollee who is an inpatient, 
regardless of where the service took place.  
 
In this case, the record shows the enrollee was an inpatient on this date of service. The POS code for inpatient 
services is 21. The record shows the claim was billed using POS code 22. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan 
does not have to pay for an abdominal x-ray provided on May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87633) provided on April 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Multiplex Polymerase chain reaction (PCR) 
respiratory viral panels of 6 or more pathogens are non-covered. 
 
We looked at the file and Medicare rules. The testing performed had 12-25 targets. Panels of 6 or more 
pathogens are not covered. 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 lab services (87633) 
provided on April 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous epidural implantation of neurostimulator 
electrode array (63650) and implantable neurostimulator electrode, each (L8680).  
You asked the Plan to pre-approve spinal cord stimulator implant trial. You say that the request was not 
approved due to medical necessity. However, per the Medicare guidelines the enrollee meets the qualifications 
for approval. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show that the enrollee has not been declared "not a surgical candidate" by a neurosurgeon or spinal 
surgeon. The enrollee does not have a condition for which this treatment is medically necessary. 
 
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 spinal cord stimulator implant trial. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back pain and is taking Codeine and an 
NSAID for pain. The enrollee has had multiple epidural steroid injections, facet injections and RFA. The 
enrollee has psychological clearance for a SCS trial. MRI shows old vertebral body fracture at the lower 
thoracic spine. (Identified as T11 in one report and T12 in another) as well as multi-level degenerative disc 
disease. The enrollee does not have an evidence-based indication for a SCS trial and has not had a surgical 
evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator implant trial have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous epidural implantation of neurostimulator electrode 
array (63650) and implantable neurostimulator electrode, each (L8680).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2022, billed with 
codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321 and 
81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
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 March 2, 2022, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 
81311, 81317, 81321 and 81194.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, routine venipuncture, and a brief 
emotional/behavioral assessment provided on June 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, routine venipuncture, and a brief emotional/behavioral 
assessment. You say that you have submitted supporting documentation and would like it reviewed. The Plan 
denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 office visit, routine venipuncture, and a brief 
emotional/behavioral assessment provided on June 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a catheterization (36246) provided on May 27, 2022. 
 
You asked the Plan to pay for the catheterization procedure. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the code billed is 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 36246 is a catheter placement. 
 
We find that CPT code 36246 is not supported in the medical record. Specifically, coding guidelines state that 
catheter placement codes should not be billed separately when via the same access as a revascularization 
procedure. The catheter placement occurred in the same site as the revascularization procedure. Based on this 
information, we decided that Medicare rules for coverage of the catheterization procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for a catheterization (36246) provided on May 27, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 71101. 
 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 71045 is a column II code to column I code 71101. 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 71045 
billed for date of service February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 13, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravascular shockwave lithotripsy (ISL) services. 
 
You asked the Plan to pre-approve ISL services. You say that this procedure is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational 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 ISL services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the medical appropriateness and necessity of ISL in managing a calcified 
stenosis in a branch of the iliac artery. There is more extensive literature on the use of ISL for calcified 
coronary artery lesions; however, there is only scant literature on the application of this technique for 
peripheral arteries. While clinical studies led to Food and Drug Administration approval several years ago, ISL 
remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. At the current time, ISL is not medically necessary for this enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ISL services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intravascular shockwave lithotripsy (ISL) services.