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

 
We decided that the Plan does not have to pay for lab services (81206, 81301, 81311) provided October 10, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says rules for coverage were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81206, 81301, 81311) provided 
October 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99100, 99140) provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
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 codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 99100 and 99140 are not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99100, 99140) provided on December 15, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on November 12, 
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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 moderate sedation services rendered on 
November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office services on March 28, 2022. 
 
You asked the Plan to waive the deductible for office services. You say that you believe this is an error and 
should be less. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $233 deductible which applies to office services. The provider billed 
in the amount of $667.68. The Plans discount is $487.87. Therefore, resulting in the total cost-sharing amount 
of $179.81. 
 
The item or service you asked the Plan to waive the deductible for office services fall within the benefit 
category Physician/Practitioner services, including doctors office visits. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $179.81 deductible which applies to deductible. This cost 
sharing is a contractual obligation that had not been met at the time office visit was received on March 28, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for office services on March 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid tubing and ear molds provided on January 6, 
2022. 
 
You asked the Plan to pay for hearing aid tubing and ear molds. You say that you sent in a claim for your 
hearing aid tubing and ear molds and the Plan was processing it. You disagree with the denial and are 
requesting reconsideration for your reimbursement. The Plan denied your request. The Plan says you have 
exhausted your maximum allowance for a hearing aid purchase, repair, replacement molds and assessments. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan contract says 
that you receive a $600 allowance for hearing aids, including purchase, repair, replacement molds and hearing 
aid assessments, every thirty-six (36) months.  
 
We looked at the file and the Plan's rules. The records show that you were reimbursed $600 for hearing aids on 
February 9, 2022, therefore, you have exhausted your maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of hearing aid tubing and ear molds have not been 
met. Therefore, we decided that the Plan does not have to pay for hearing aid tubing and ear molds provided on 
January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on December 9, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 37600 is ligation; external carotid artery. The CPT Code 
Manual definition of code 31525 is laryngoscopy direct, with or without tracheoscopy; diagnostic, except 
newborn. We find that CPT code 37600 and 31525 were provided during a radical resection of the tonsils. The codes at 
issue are considered integral to the primary procedure. Accordingly, it is inappropriate to separately report 
these services. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided 
on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the level IV surgical pathology, gross and microscopic 
examination (88305) and special stain including interpretation and report (88312) provided on December 23, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are disputing or medical necessity. 
Please review the attached 12 pages of medical records and reprocess the claim. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 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 level IV surgical pathology, gross and 
microscopic examination (88305) and special stain including interpretation and report (88312) provided on 
December 23, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant 360 liquid biopsy (0242U). 
 
You asked the Plan to pay for laboratory services. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the Medicare rules for coverage of testing 
services have not been met. 
 
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 pay for laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the available documentation does not support that tissue-based comprehensive genomic 
profiling was infeasible for the enrollee in this case. The available records do not sufficiently support that the 
Guardant360 liquid biopsy testing was medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant 360 liquid biopsy (0242U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on January 19, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement in place that indicates 
the codes are included in the dialysis rate. The Plan denied your request. The Plan says the lab services are the 
responsibility of the enrollee's dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing services provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia procedures provided on October 6, 2020. 
 
You asked the Plan to pay for anesthesia procedures. The Plan denied your request. The Plan says Medicare 
denies a claim if it is not received by the Plan within 12 months or 1 calendar year from the date when the 
services were rendered. 
 
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 anesthesia procedures was not filed until February 10, 2022. 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 anesthesia procedures provided on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing provided on December 14, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing reduces the number of unnecessary 
biopsies. The Plan denied your request. The Plan says there is insufficient evidence that it is of any medical 
benefit. 
 
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 pay for the testing services. Our physician reviewer 
found that the enrollee has an elevated prostate specific antigen level and an enlarged prostate on digital rectal 
exam. There is no documentation as to how the results of the SelectMDx gene testing would impact clinical 
management of the enrollee in this case. There is no documentation that the services at issue in this case meet 
Medicare criteria for being medically reasonable and 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 the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the SelectMDx testing provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 29, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service October 21, 
2021. 
 
You asked the Plan to pay for procedure code 93010. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 93042. 
 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 93010 
is a column II code to column I code 93042. 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 93010 billed for date of service October 21, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you fear for your safety if you return home before 
receiving IRF care. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. Your care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 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 January 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins (93971) provided on July 4, 
2021. 
 
You asked the Plan to pay for the duplex scan. You say that this service was billed appropriately. The Plan 
denied your request. The Plan says this service was not billed with an appropriate diagnosis code to support the 
medical necessity of this service by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 93971 is not supported as billed. Specifically, this service was reported with ICD-10-
CM code M79.89. This diagnosis code is not included on the list of appropriate diagnosis codes to support the 
medical necessity of 93971. Based on this information, we decided that Medicare rules for coverage of the 
duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for duplex scan of 
extremity veins (93971) provided on July 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) provided on June 9, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that resubmitting the claim with supporting 
documentation to support CPT code G0483. Please review and reprocess for payment. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 definitive drug testing (G0483) provided on 
June 9, 2021 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 specialist's visit on January 14, 2021. 
 
You asked the Plan to waive the copayment for specialist's visit. You say that you should not have to pay a 
copayment. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $30 copayment for Specialists Office. Covered services include: Consultation, diagnosis, and 
treatment by a specialist. 
 
The enrollee has been asked to pay a $30 copayment for specialist's visit. Specialist's visits fall within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for specialist's visit on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a primary care (PCP) office visit provided 
on December 1, 2021. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that you only saw the receptionist 
who informed you that your appointment was canceled. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
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 20% 
coinsurance for services obtained from a primary care provider.  
 
The record shows that you were seen and evaluated on December 1, 2021. Therefore, you have been asked to 
pay $17.94, which is 20% of the allowed amount for the office visit ($89.70 allowed amount x 20% 
coinsurance = $17.94). The office visit falls within the Physician/Practitioner Services, Including Doctor's 
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 coinsurance for a primary care (PCP) 
office visit provided on December 1, 2021.