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

 
We decided that the Plan does not have to pay for the laboratory services coded81120, 81121, 81194, 81206, 
81210, 81235, 81245, 81270, 81272, 81275, 81276, 81310, 81311, 81315, and 81351 provided on April 6, 
2021. 
 
You asked the Plan to pay for the laboratory services. 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 81120, 81121, 81194, 81206, 81210, 81235, 81245, 81270, 81272, 81275, 81276, 
81310, 81311, 81315, and 81351 are not supported in the medical record. Specifically, if a laboratory assays 
two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. 
A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file 
does not support that only one code was billed for the panel provided. 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 coded81120, 81121, 81194, 81206, 81210, 81235, 81245, 
81270, 81272, 81275, 81276, 81310, 81311, 81315, and 81351 provided on April 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on February 10, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health care. You say that you are trying to get paid for having people come 
to your house to help take care of your wife in her last days of life. The Plan denied your request. The Plan says 
the service obtained by the member was rendered by a provider who is not under contract with the Plan and is 
not certified for Medicare. 
 
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 home health care provided on February 10, 2021, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you never had to pay 
copayment before, and your husband didn't have to pay for his procedure so you shouldn't have to pay for 
yours. 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 $225 
copayment for each Medicare covered ambulatory surgical center visit. 
  
You have been asked to pay $225 copayment for diagnostic colonoscopy. Diagnostic colonoscopys fall within 
the Outpatient Surgery Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 diagnostic colonoscopy 
provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 13, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on April 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair seating modifications (CPT 
code(s): K0739, E2607 and K0108). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. The Plan states replacement of the chair is 
recommended. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Your records must show you meet 
these criteria: It costs less to repair your current wheelchair than to replace it. The cost of chair modifications 
exceeds the cost of replacing the chair with the requested features. Therefore, we decided that the Plan does not 
have to pre-approve the power wheelchair seating modifications (CPT code(s): K0739, E2607 and K0108).
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 need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy on an intensive IRF level. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional home health skilled nursing visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that based on the medical records provided, there is no documentation that additional skilled nursing 
services beyond what have already been approved are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the patient's condition and/or prevent deterioration. The provided records do not document any acute 
or unstable medical conditions or changes in medication or treatment which would necessitate any further 
skilled nursing visits beyond what have already been approved. No medical notes from the enrollees treating 
physician are provided documenting an order or need for additional skilled nursing services beyond what have 
already been approved. The records do not document the need for intravenous medications, new tube feeding 
or ostomy care or daily complex wound 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five additional home health skilled nursing visits for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 procedure code 76705 billed for date of service March 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
November 8, 2021, to December 16, 2021. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you never had 
copayments before so they should be covered now. The Plan denied your request. The Plan says the 
copayments applied are 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 
copayment for each Medicare-covered physical therapy and speech-language therapy visit.  
 
 
 
 
 You have been asked to pay $400 (10 visits x $40) copayment for physical therapy visits. Physical therapy 
visits fall within the Outpatient Rehabilitation 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 copayments for physical therapy visits provided from November 8, 2021, to December 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Combigan. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Combigan.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $62.78 coinsurance for a CGM received on February 11, 
2022.  
 
You asked the Plan to waive the $62.78 coinsurance for a CGM received on February 11, 2022. You say that 
you have never paid for this item before. The Plan denied your request. The Plan says you are responsible for a 
20% coinsurance for Medicare-covered equipment and supplies received from an in-network provider. 
 
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 Durable Medical Equipment (DME) and Related Supplies.  
 
 
 
 
 
 
 You have been asked to pay a $62.78 coinsurance for a CGM. A CGM falls within the Durable Medical 
Equipment (DME) and Related Supplies benefit category. The Plans allowance was $313.92; your coinsurance 
is 20% of the Plans allowed amount. $313.92 x 20% = $62.78. 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 $62.78 
coinsurance for a CGM received on February 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that there are no medical issues that require 
treatment at this level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected this enrollee would improve in a reasonable period of time as she does not have suicidal or 
homicidal ideation, auditory or visual hallucinations. The patient was compliant with treatment while not 
showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care as she does not have 
dangerousness to self or others and was compliant with her treatment. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 16, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were provided in a 
nursing home where the patient was residing and the nursing home ordered these services. The Plan denied 
your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on February 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the anesthesia provider, the surgeon, nor the facility where the procedure took place are network 
providers 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 anesthesia services provided on February 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for eye imaging and an ophthalmology office 
visit provided on February 23, 2022. 
 
You asked the Plan to waive the copayments for eye imaging and office visit. You say that the Plan should 
cover all costs after the enrollee paid a $35 copayment. The Plan denied your request. The Plan says the 
copayment amounts the enrollee is being charged are 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 $75 copayment for eye imaging and $43 copayment for office visit from an in-network specialist. The 
allowed amount of the eye imaging is $31.10, which is less than the copayment amount of $75. Therefore, the 
enrollees total copayment obligation is $74.10. 
 
The enrollee has been asked to pay less than the $75 copayment for eye imaging and $43 copayment for office 
visit. Eye imaging and office visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 copayments for eye imaging and an ophthalmology office visit 
provided on February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that radiofrequency ablation of the nerves innervating the sacroiliac 
joint has not been proven as effective as standard treatment of sacroiliac joint pain. 
 
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 pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Radiofrequency 
ablation of the sacroiliac joint innervation is considered experimental/investigational because of the wide 
variation in efficacy reported in the literature. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance 
(64625) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services (V5267 and V5298) provided on 
September 15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid services. You say that there are no facilities within 100 miles of 
your location. The Plan denied your request. The Plan says these services were rendered by a provider who is 
not part of the Plan's vendor network. 
 
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 hearing aid vendor to use 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 aid services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hearing aid services (V5267 and V5298) provided on September 15, 2021 by an out-of-network 
(OON) provider.