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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service  
April 6, 2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. 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 May 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 30, 
2021, to February 24, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like the timely filing of 
the RAP to be bypassed. The Plan denied your request. The Plan says the non-contracted provider submitted 
the RAP claim on June 28, 2021, for the home health care period which started on January 30, 2021, and ended 
on February 24, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided from January 30, 2021, to February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services (J3490) provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the 
global surgical payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for the following services related to the surgery when furnished by the 
physician who performs the surgery.  
 We looked at the file and Medicare rules. The requested services are included in the global surgical payment 
for the procedure  (27096) provided on the same day. The requested services 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 drug services (J3490) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the polycarbonate lenses (V2784), 
photochromatic tint (V2744), and anti-reflective coating (V2750) provided May 16, 2022. 
 
You asked the Plan to waive the copayment for the polycarbonate lenses with photochromatic tint and anti-
reflective coating. You say that you were told the features you chose were included in your coverage. The Plan 
denied your request. The Plan says the copayments have been 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 that you must pay 
additional copayments for lens enhancements.  
 You have been asked to pay a total of $172 for the lens enhancements ($31 copayment for the polycarbonate 
lenses, $72 copayment for photochromatic tint and a $69 copayment for the anti-reflective coating). The 
polycarbonate lenses with photochromatic tint and anti-reflective coating falls within the lens enhancement 
section of the Vision 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 the 
polycarbonate lenses (V2784), photochromatic tint (V2744), and anti-reflective coating (V2750) provided May 
16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22551 billed for date of service September 
10, 2021. 
  You asked the Plan to pay for procedure code 22551. You say that this is not bundled with 22849. You say that 
the records should be reviewed, and the claim allowed for payment. The Plan denied your request. The Plan 
says payment for code 22551 is bundled into payment for code 63081. 
 
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 22551 
is a column II code to column I code 63081. 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 22551 billed for date of service September 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) gene analysis 
(81232) billed for date of service April 25, 2022. 
 
You asked the Plan to pay for DPYD testing. You say that this test is medically necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this service is not considered reasonable and 
necessary by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. Code 81232 is listed under the Group 3 Paragraph of Article A56199. 
This means that this service is considered automatically denied as not medically necessary. Therefore, we 
decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) gene analysis 
(81232) billed for date of service April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you trust this physician for your ongoing 
continued care and are asking for approval. The Plan denied your request. The Plan says the medical care you 
require can be provided by a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
an office visit to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Continuous passive motion (CPM) exercise device for 
use other than knee (E0936). 
 
You asked the Plan to pre-approve the CPM device. You say that please review your past medical records to 
see you have been suffering with shoulder and arm problems on both sides for well over 3 years. The Plan 
denied your request. The Plan says Medicare only covers this device after certain types of knee surgery. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve Continuous passive motion (CPM) exercise device for use other than knee (E0936).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro powered arm brace (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is a covered device within the 
DME benefit category under Original Medicare. The Plan denied your request. The Plan says there is not 
enough studies to show that the Myopro will help in the enrollee's care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Myopro powered arm brace (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis treatments provided from May 4, 
2022, to May 30, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis treatments. You say that you cannot afford this large 
payment amount. The Plan denied your request. The Plan says you were charged this cost sharing 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 20% 
coinsurance for outpatient hospital services ($67.34 per treatment x 9 treatments = $606.06).  
 
You have been asked to pay a total of $606.06 coinsurance for dialysis treatments. Dialysis treatments fall 
within the Outpatient Hospital 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 coinsurance 
for dialysis treatments provided from May 4, 2022, to May 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit, nerve conduction test, and 
EMG provided on February 23, 2022. 
 
You asked the Plan to waive the deductible for an office visit, nerve conduction test and EMG. You say that 
you should not be responsible to pay this because you were not told the provider was not in-network. The Plan 
denied your request. The Plan says the deductible has been applied correctly. 
 
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 $750 deductible which applies to consultation, diagnosis, and treatment 
by a specialist.  
 
The item or service you asked the Plan to waive the deductible for falls 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 $750 deductible which applies to Physician/Practitioner 
Services, Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at 
the time an office visit, nerve conduction test and EMG were received on February 23, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for an office visit, nerve conduction test, and 
electromyography (EMG) provided on February 23, 2022.  Please note, you stated in your appeal that these services were rendered on February 22, 2022. The medical 
records show that the services at issue were provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interrogation device evaluation provided on March 19, 
2022, by an OON provider. 
 
You asked the Plan to pay for an interrogation device evaluation. You say that you are appealing the denial of 
the claim for this date of service. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
 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 interrogation device evaluation provided on 
March 19, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014), visual field examination (92083), and 
fundus photography (92250) provided on May 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam, visual field examination, and fundus photography. The Plan 
denied your request. The Plan says these services were rendered by an OON provider, and prior authorization 
was not obtained. 
 
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 
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 eye exam (92014), visual field examination 
(92083), and fundus photography (92250) provided on May 24, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says 
admission to LTACH was denied as not meeting criteria, is not medically necessary, and continued acute 
hospital stay was offered, until the enrollee could discharge to a lower level of care like a skilled nursing 
facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted on September 15, 2022, with abscess on the left knee. On 
September 19, 2022, the enrollee had an incision and drainage of the knee with Prostalac placement and wound 
vac placement. September 27, 2022 the enrollee had the right knee hardware removed and Protalac placement. 
The enrollee will require IV antibiotics for six weeks with ongoing wound vac changes every forty-eight hours.  
 There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee does 
not require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration for payment. 
 The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 x-ray provided on February 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you are only 4.3 miles over the 30-mile 
limit, and need a wheelchair van to get to the doctor's because it causes you too much pain to get in and out of 
normal cars. The Plan denied your request. The Plan says non-emergent transportation outside of your 30-mile 
contractual limit cannot be covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the trip does not exceed 30 miles one-way.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional transportation mileage.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 vaccine provided to the enrollee on December 21, 2021. 
 
You asked the Plan to pay for the vaccine. You say that the denial statement is vague, and the vaccine has been 
approved by the federal government. The Plan denied your request. The Plan says that Medicare payment for 
COVID vaccinations administered in 2020 and 2021 will be made through the Medicare Fee For Service 
program. 
 
The Plan must follow Medicare rules. Medicare rules say that the COVID-19 vaccine is covered. 
 
The rules say that this denied vaccine is covered by Medicare. Based on this information, we decided that 
Medicare rules for coverage of the vaccine have been met. Therefore, we decided that the Plan has to pay for 
the COVID-19 vaccine provided to the enrollee on December 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 22, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting a reconsideration and are 
submitting documentation for review. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
 
 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 provided on September 22, 2021, by 
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided April 26, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you did not need to go to the hospital. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 26, 2022. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided April 26, 2022.