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

 
We decided that the Plan does not have to pay for the laboratory services (88104, 88305, 88312, and 88361) 
provided on September 27, 2021. 
 
You asked the Plan to pay for codes 88104, 88305, 88312, and 88361. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (88104, 88305, 88312, and 88361) provided on September 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5130 billed for date of service April 2, 
2022. 
 
You asked the Plan to pay for procedure code S5130. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5130 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5130 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5130 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5130 billed for date of service April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and the intraoral complete 
series of radiographic images received on May 26, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and the intraoral complete series of 
radiographic images. You say that you went for a cleaning procedure, but the provider performed other services 
you did not ask for. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral exam service was exhausted on date of service February 7, 
2022. The record shows your benefit for the intraoral complete series of radiographic images was exhausted on 
date of service July 20, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation and the intraoral complete series of radiographic images received on May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement rendered on September 28, 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 11000 is not supported. 
 
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 11000 is debridement of extensive eczematous or 
infected skin; up to 10% of body surface. 
 
We find that CPT code 11000 is not supported in the medical record. Specifically, there is no documentation of 
debridement of extensive eczematous or infected skin for up to 10% of the body surface. 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 debridement rendered on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88112, 88305, 88312 and 
88361 provided on February 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's 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 code 88112, 88305, 88312 and 88361 is not supported in the medical record. Specifically, 
these codes have a professional component/technical component indicator of 1. This claim was billed with 
place of service 22 (outpatient hospital). The professional interpretation was furnished in the same payment 
locality from where the technical component was furnished. We find that the Medicare rule for payment of this 
claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting physician. This means these services are not payable as billed. 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 laboratory services coded 88112, 88305, 
88312 and 88361 provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management (99397) provided on April 7, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that this has been covered in 
the past. The Plan denied your request. The Plan says the benefit limit has been exhausted. 
 
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 there is a $0 copayment for 
a routine physical exam each year. 
 
You have been asked to pay the full amount for the evaluation and management service. The evaluation and 
management service falls within the Annual Routine Physical Exam benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The record shows that the Plan paid for a routine 
physical exam that you received on February 4, 2022, thus exhausting the benefit of one each year. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation 
and management (99397) provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 
provided on April 13, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 code 81455 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on April 26, 2021. The billed date of service was April 13, 2022. This means 
that there is no documentation to support the testing on the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel 
coded 81455 provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that this claim was billed incorrectly. The Plan 
denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation (D0150) 
provided on May 10, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81455) provided April 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. There is no documentation describing genetic testing on a sample 
collected on the date of service at issue. 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 the 
lab services (81455) provided April 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx testing rendered on February 23, 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 that the claim was not billed with the required unique test identifier. 
 
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 Plan references Local Coverage Determination (LCD) L35025 and Local 
Coverage Article (LCA) A56853 in their determination; however, these rules are not binding for the state of 
Massachusetts where the single-source testing was performed. The Plan has not provided any valid Medicare 
rules to support that the services are not payable as billed. Therefore, we decided that the Plan has to pay for 
the FoundationOne CDx testing rendered on February 23, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
18, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the provider did not 
address your issue at this visit. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $78.20 copayment, rather than the full copayment amount of $90 for an 
emergency room visit. An emergency room visit falls within the Emergency 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 an emergency room visit provided on May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 27, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that this should not have a copayment. You 
had the same thing done last year and it did not have a copayment. 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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $109.98 copayment, rather than the full copayment amount of $275 for a CT 
scan. A CT scan falls within The Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) 
scan provided on May 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a diagnostic colonoscopy provided on May 19, 
2022. 
 
You asked the Plan to waive the cost for a diagnostic colonoscopy. You say that this was supposed to be a 
screening without a copayment. The Plan denied your request. The Plan says the cost that was applied was 
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 a $2000 
deductible for colorectal cancer screening.  
 
You have been asked to pay $400 towards your deductible, and $1.10 coinsurance, for a diagnostic 
colonoscopy ($400 deductible + $54.07 x 2% = $1.10 coinsurance = $401.10). A diagnostic colonoscopy falls 
within the Colorectal Cancer Screening 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 cost for a 
diagnostic colonoscopy provided on May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea injections. 
 
You asked the Plan to pre-approve Eylea injections. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea injections. Our reviewer says that 
the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of exudative age-related macular degeneration, left eye, with active 
choroidal neovascularization. The documentation does not support that the enrollee has tried and failed 
Lucentis. The documentation does not support that Lucentis would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Eylea injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88112, 88305, 88312, 88361) provided on 
March 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the codes 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. 
 
We find that CPT codes 88112, 88305, 88312, and 88361 are not supported in the medical record. Specifically, 
these services have a professional component / technical component indicator of 1. The services were billed 
with place of service 22 (outpatient hospital). Interpretation of a diagnostic test must be separately billed with 
modifier 26 by the interpreting physician. 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 (88112, 88305, 88312, 88361) provided on March 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on April 15, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you received subpar 
care that put you in danger of a more serious injury. You don't feel that the plan or you should be responsible 
for the bill. 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). Your contract with the Plan clearly says that you must pay a $90 
copayment per emergency care visit. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 emergency 
room services on April 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
to the enrollee from January 11, 2022, to January 21, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that the enrollee had to stay at the 
facility longer due to contracting COVID-19. The Plan denied your request. The Plan says the enrollee was 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 per day for days 1-20 and $184 per day for days 21-100 for each benefit period. 
 
Dates of Service Benefit Days Copayment 
December 22, 2021  January 10, 2022 1-20 $0/day 
January 11, 2022  January 21, 2022 21-30 $184/day 
Total:  $1,840 The enrollee has been asked to pay $184 per day for days 21-30 of SNF care, for a total of $1,840. The SNF 
care falls within the Skilled Nursing Facility (SNF) Care 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 skilled nursing facility (SNF) care provided to the enrollee from January 11, 
2022, to January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a non-routine foot care visit provided on 
March 14, 2022. 
 
You asked the Plan to waive the copayment for a non-routine foot care visit. You say that the visit was routine, 
and you were not fitted for diabetic shoes. You say the visit was billed incorrectly and you believe it is fraud. 
The Plan denied your request. The Plan says the copayment 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 a $35 
copayment for each non-routine Medicare-covered foot care visit.  
 
You have been asked to pay a $35 copayment for a non-routine foot care visit. A non-routine foot care visit 
falls within the Podiatry Services - Medicare-covered 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 non-routine foot care visit provided on March 14, 2022.  
 Your complaint about the visit being billed incorrectly 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided May 19, 2022. 
 
You asked the Plan to pay for paramedic intercept services. You say that the ambulance team felt it was 
medically necessary to call paramedics. The Plan denied your request. The Plan says this service is not 
covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided May 19, 2022.