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

 
We decided that the Plan does not have to pay for annual wellness visit, an office visit, and a drug test provided 
on March 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for annual wellness visit, an office visit, and a drug test. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says these services provided by a 
non-contracted provider remains upheld as the claim does not meet the urgent or emergent criteria based on the 
codes submitted. The Plan also says that there is no documentation that this member was referred to this non-
contracted provider by a contracted provider, as well as no indication that any attempt was made to obtain prior 
authorization for the out-of-network services.  
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 annual wellness visit, an office visit, and a drug 
test provided on March 10, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 21, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this was a follow-up visit 
after surgery and the claim should be included in the surgical billing process. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $45 
copayment for a specialist office visit.  
 
The Plan confirmed you had surgery on August 23, 2021, therefore the office visit on December 21, 2021 does 
not fall within the 90-day global billing period. You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office 
Visits 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 a specialist office visit provided 
on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pathnostics Guidance UTI panel coded as 87481, 87496, 
87500, 87529, 87532, 87653 87640, 87651, 87798 and 87801 provided February 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee's physician ordered the 
medically necessary guidance UTI test. You disagree with the adverse determination and request 
reconsideration for payment based on the information provided. The Plan denied your request. The Plan says 
qualitative PCR testing is considered experimental and investigational because of insufficient evidence in the 
peer reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
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. Therefore, we decided that the Plan does not have to pay 
for the Pathnostics Guidance UTI panel coded as 87481, 87496, 87500, 87529, 87532, 87653 87640, 87651, 
87798 and 87801 provided February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 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 are not billed correctly. 
 
 
 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 these 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 rendered on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided by Sportsmed Pt LLC, from 
October 27, 2021, through November 1, 2021. 
 
You asked the Plan to pay for acupuncture treatment. You say that  The Plan denied your request. The Plan 
says this provider is not supervised by any physician, PA, or NP/CNS. 
 
 The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided by 
Sportsmed Pt LLC, from October 27, 2021, through November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing provided on October 12, 2020. 
 
You asked the Plan to pay for the COVID-19 testing. You say that the claim should be processed as providers 
were not able to bill timely during the public health emergency. The Plan denied your request. The Plan says 
the one-year claim filing deadline was not waived during the pandemic. The provider failed to submit a claim 
within this time frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the COVID-19 testing was not filed until October 21, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the COVID-19 testing provided on October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
August 17, 2021, to August 20, 2021. 
 
You asked the Plan to waive the copayment for inpatient admission. You say that you are upset over what was 
billed and you feel you were handled inappropriately. The Plan denied your request. The Plan says the 
copayment was applied 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 each time you are admitted 
to an acute care hospital, you must pay $275 per day for days 1-5 and $0 after day 5 for inpatient hospital stays.   
 You have been asked to pay a total of $825 ($275 copayment x 3 days = $825). Inpatient hospital stays fall 
within the Inpatient hospital 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 inpatient hospital stay provided from August 17, 2021, to August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 25, 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 services are 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, 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 the computed tomography (CT) scan of the head/brain rendered 
on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 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. 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 these 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 rendered on July 20, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Hematology Profile Plus testing (81455) provided on May 3, 2021. 
 
You asked the Plan to pay for Hematology Profile Plus testing. You say that this was medically necessary. The 
Plan denied your request. The Plan says that genetic testing procedures submitted with code 81455 are unlikely 
to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary. 
 
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 Local Coverage Determination and Article the Plan cites do not state that 
the code at issue is non-covered. The record shows that the specific testing at issue has undergone a Technical 
Assessment through MolDX and is covered by Medicare. The Plan has not provided information supporting the 
denial of this service. Therefore, we decided that the Plan has to pay for Hematology Profile Plus testing 
(81455) provided on May 3, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair 
(E2377, E2313, E2311). 
 
You asked the Plan to pre-approve the expandable controller for a power wheelchair. You say that the 
controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
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 expandable controller for a power 
wheelchair. Our reviewer says that the expandable controller is not medically necessary. Our physician 
reviewer found the enrollee has adequate upper extremity strength and function to operate the wheelchairs 
power options with their own switches. 
 
 
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 expandable controller for a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, 
E2313, E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 17, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on October 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Gene Sight Psychotropic test (81479) provided November 
21, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you provided the Guardant Reveal molecular 
diagnostic test at the request of the ordering physician. The Plan denied your request. The Plan says this service 
is considered experimental and investigational as there is insufficient data to recommend the use of post-
surgical DNA to determine risk of recurrence or use of adjuvant therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for Gene Sight Psychotropic test (81479) provided November 21, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacy dispensing fees rendered on June 18, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of E are 
excluded from the physician fee schedule by regulation. 
 
We looked at the file and Medicare rules. Billed procedure code Q0514 has a status indicator of E and is 
excluded from payment. Therefore, we decided that the Plan does not have to pay for the pharmacy dispensing 
fees rendered on June 18, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. 
 
You asked the Plan to pre-approve facet joint interventions. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet joint interventions. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have multiple pain 
generators. Facet joint injections do not meet LCD criteria when there are other probable pain generators that 
have not been addressed. At this point, the request is 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 facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions.
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 October 4, 2021, to November 2, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says custodial services or supplies are not covered. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 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 October 4, 2021, to 
November 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 29,
2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the Centers for Medicare and Medicaid Services (CMS) website, shows the member was
enrolled in hospice from April 02, 2020 through April 23, 2020 and May 16, 2020 through June 27, 2020. In
accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers,
for services rendered on April 29, 2020. Per the regulations, the claim would be covered under Original
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of
the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
This appeal will only address the claims for date of service April 29, 2020. The related claims for services
received from physicians, for date of service April 23, 2020, April 28, 2020, and April 30, 2020 are being addressed under separate cases

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee on April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an inhaler compressor purchased on December 3, 2019.

You asked the Plan to reimburse you for the inhaler compressor. The Plan denied your request. The Plan says an inhaler compressor is not listed in the Plan's 2019 OTC Catalog as an eligible item for reimbursement.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the Plan offers an OTC benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the rules. The file shows that the inhaler compressor is not listed in the Plan's 2019 OTC Catalog as an eligible item for reimbursement. Therefore, we decided that the Plan does not have to reimburse you for an inhaler compressor purchased on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty (D7320).

You asked the Plan to pre-approve an alveoloplasty. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the requested service is not listed in the Plan's supplemental dental benefit chart. Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty (D7320).