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

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 24, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services were billed incorrectly. 
 
 
 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 drug testing 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 drug testing coded G0483 provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this device is medically necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January 
12, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed 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, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 8. This code was billed with a place of service 22 (outpatient hospital) 
which is considered an inappropriate place of service. Based on this information, we decided that Medicare 
rules for coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not 
have to pay for the blood smear services coded 85060 provided on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography services coded 70450 provided on 
November 27, 2021. 
 You asked the Plan to pay for the computed tomography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed 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 services coded 70450 provided on 
November 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5257) and handling, conveyance, and/or 
any other service in connection with the implementation of an order involving devices (99002) provided on 
February 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids and handling, conveyance, and/or any other service in 
connection with the implementation of an order involving devices. You say that you went to a Plan-approved 
hearing aid provider but had a bad experience. You also say that you later went to an audiologist to purchase 
new hearing aids. The Plan denied your request. The Plan says you received the hearing aids from a provider 
who is not plan-approved. The Plan also says that the handling, conveyance, and/or any other service in 
connection with the implementation of an order involving devices is not covered by Medicare or your plan. 
 
  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 pays for 
hearing aids only when you use the Plan's approved hearing aid brand, and a Plan approved hearing aid 
provider is used to receive your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids and handling, conveyance, and/or any other service in connection with the 
implementation of an order involving devices have not been met. Therefore, we decided that the Plan does not 
have to pay for the hearing aids (V5257) and handling, conveyance, and/or any other service in connection with 
the implementation of an order involving devices (99002) provided on February 22, 2021 by an out-of-network 
(OON) provider.  
 
Your complaint about the bad experience you had with the Plan-approved hearing aid vendor is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wheelchair, wheelchair accessories 
and commode chair provided from August 27, 2021, to October 27, 2021. 
 
You asked the Plan to waive the coinsurance for the wheelchair, wheelchair accessories and commode chair. 
You say that you are being charged for a wheelchair you already returned and oxygen equipment you never 
received, so this should be covered. The Plan denied your request. The Plan says the coinsurance applied 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). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for durable medical equipment from an out of network provider.  
  You have been asked to pay a total of $84.76 for the wheelchair, wheelchair accessories and commode chair. 
 
Date of Service Equipment Allowed Amount Coinsurance Member Liability 
August 27, 2021 Commode Chair, 
Wheelchair & Accessories 
$153.98 40% $49.54-less than 
standard 40% 
September 27, 2021 Wheelchair & Accessories $44.03 40% $17.61 
October 27, 2021 Wheelchair & Accessories $44.03 40% $17.61 
TOTAL:    84.76 
 
The wheelchair, wheelchair accessories and commode chair fall 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. Therefore, we decided that the Plan does not have to waive the coinsurance for the wheelchair, 
wheelchair accessories and commode chair provided from August 27, 2021, to October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 21, 2020.  You asked the Plan to pay for physical therapy services. You say that you did not have sufficient staff to work 
on billing due to the COVID-19 crisis and later found that the providers were not listed within the Plan 
database. You say that the medical records required to reprocess the denied claim are attached. The Plan denied 
your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on August 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the chest (71046). 
 
You asked the Plan to pay for the X-ray exam of the chest. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed with 
an appropriate modifier required by Medicare billing regulations. 
 
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 looked at the file and Medicare rules. The records show that the code was billed without a modifier, 
meaning that you are requesting payment of the technical component and the professional component. 
However, the place of service billed on this claim was a skilled nursing facility. This means that the skilled 
nursing facility is paid for the technical component of the service. This claim has not been billed with the 
correct modifier to indicate payment is requested only for the professional component. Based on this 
information, we decided that Medicare rules for coverage of the X-ray exam of the chest have not been met. 
Therefore, we decided that the Plan does not have to pay for the X-ray exam of the chest (71046).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on September 7, 2021. 
 
You asked the Plan to pay for the physician service. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. You also say that this has been denied in error. The Plan denied your request. 
The Plan says the enrollees 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. 
The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit (99213) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) coded 95813 and 95812 
and the short-latency somatosensory evoked potential study coded 95938 provided on October 27, 2021. 
 
You asked the Plan to pay for the electroencephalogram (EEG) and the short-latency somatosensory evoked 
potential study. You say that you would like the plan to reconsider their denial. The Plan denied your request. 
The Plan says the services are not payable as billed. 
 
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 95813, 95812, and 95938 are not supported in the medical record. Specifically, these 
services were billed by a provider that is not a recognized facility or a legally qualified physician. The services 
were provided for the physician and/or the facility, not at the request of the enrollee. This means that these 
services are not payable. The plan also states that you, the provider should contact the physician and/or facility for any reimbursement request. Based on this information, we decided that Medicare rules for coverage of the 
electroencephalogram (EEG) and the short-latency somatosensory evoked potential study have not been met. 
Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) coded 95813 and 
95812 and the short-latency somatosensory evoked potential study coded 95938 provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management visit (99443) 
provided on September 21, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that please see attached medical notes and 
reconsider the claim 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 telephone evaluation and management visit 
(99443) provided on September 21, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on 
February 3, 2022. 
 You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 coded 70450 provided on February 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint blocks. 
 
You asked the Plan to pre-approve facet joint blocks. You say that facet joint blocks are medically necessary. 
The Plan denied your request. The Plan says the facet joint blocks do not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 blocks. Our reviewer says 
that the requested facet joint blocks are not medically necessary. Our physician reviewer found the result 
should be considered negative as the pain generator and it should not be repeated. 
 
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 blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint blocks.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on February 1, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. 
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed appropriately by 
Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
purchased on July 26, 2021. 
 
You asked the Plan to pre-approve the device. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare only covers this as a rental. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP must be rented to be covered.  
 
This item is not covered when it is purchased. Based on this information, we decided that Medicare rules for 
coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous positive airway pressure (CPAP) device purchased on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visit provided on December 23, 
2021. 
 
You asked the Plan to waive the coinsurance for office visit. You say that you thought you would only be 
charged $35 and don't understand why its $103.89. The Plan denied your request. The Plan says the 
coinsurance applied 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 50% coinsurance for out of network per provider per day for each Medicare-covered specialist office 
visit. 
 
 
 The enrollee has been asked to pay $103.88 which is 50% of the allowed amount for an out of network office 
visit. The allowed amount is $207.77 (50% x 207.77 = $103.88). Office visits fall within the 
Physician/Practitioner services, including doctors 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 coinsurance for office visit provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health certification visit provided on December 12, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for certification visit. You say that you rely on facility staff to verify eligibility and 
obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because this provider is out-of-network with the Plan and 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 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 a home health certification visit provided on 
December 12, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (single view) rendered on July 10, 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 procedure code 71045 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, we have confirmed that code 71045 
is a column II code to column I code 71046. 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 chest x-ray (single view) rendered on July 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided on December 30, 
2021 to February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you thought the provider was in-network. The Plan 
denied your request. The Plan says the services were rendered by an out-of-network provider without prior 
authorization. 
 
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 neuromuscular 
stimulator provided on December 30, 2021 to February 28, 2022 by an out-of-network (OON) provider.