Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit (99285) provided November 13, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that the claim originally denied for provider type. 
The claim was refiled and denied as duplicate. Please review and reprocess for payment. The Plan denied your 
request. The Plan says that this is a duplicate claim that has already been considered for payment. 
 
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 has denied payment stating this is a duplicate claim that has already 
been considered for payment. The case file consisted of an Explanation of Benefits dated 12/24/2021 with a 
denial of a duplicate claim and another Explanation of Benefits dated 12/29/2021 also with a denial of a 
duplicate claim. The Plan has not provided an Explanation of Benefits showing that this claim was actually 
paid. Therefore, we decided that the Plan has to pay for the emergency department visit (99285) provided 
November 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ThyGenX/ThyGeNEXT Oncogene panel provided on 
November 3, 2021.  
You asked the Plan to pay for the ThyGenX/ThyGeNEXT Oncogene panel. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The ThyGenX/ThyGeNEXT Oncogene panel test at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the ThyGenX/ThyGeNEXT Oncogene panel provided on November 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) and 
psychotherapy visit (90837) provided February 3, 2022 to February 16, 2022 by a licensed professional 
counselor. 
 
You asked the Plan to pay for the psychotherapy services. You say that your therapist is willing to sign up to be 
a Medicare provider, but it takes months to accomplish that. You cannot stop therapy now and wait for 
insurance coverage. The Plan denied your request. The Plan says services were rendered by an ineligible 
provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation 
(90791) and psychotherapy visit (90837) provided February 3, 2022 to February 16, 2022 by a licensed 
professional counselor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on July 29, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a more 
appropriate modifier is 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 services at issue were not billed with a modifier indicating a return trip to the operating room.  
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on July 29, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81225, 81226, 81227, 81230, 81231, 81232, 
81355, 81381, 81381, 81240, 81241, 81283, 81328, 81335, 81350) provided January 11, 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 claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (81225, 81226, 81227, 81230, 81231, 81232, 
81355, 81381, 81381, 81240, 81241, 81283, 81328, 81335, 81350) provided January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (20930) provided to the enrollee on July 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says no separate payment can be made. 
 
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 20930 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 20930 is 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 surgical 
services (20930) provided to the enrollee on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01480 provided on December 
15, 2021. 
 
You asked the Plan to pay for the anesthesia 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 01480 is anesthesia for open procedures on bones of 
lower leg, ankle, and foot; not otherwise specified. 
 
We find that CPT code 01480 is not supported in the medical record. Specifically, this service is incidental to 
the procedure performed. This means this code is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services coded 01480 provided on December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on February 9, 2022. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided medical records 
to support the services billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the services at issue are inclusive to another billed code. 
 
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 a computed tomography (CT) scan of the head or brain (70450) 
provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided on March 15, 2022. 
 
You asked the Plan to pay for localized delivery of antimicrobial agents via a controlled release vehicle into 
diseased crevicular tissue, per tooth. You say that you have money left from last year that should have been 
applied to payment of this service. The Plan denied your request. The Plan says there is no coverage for 
localized delivery of antimicrobial agents. 
 
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.  
 
 We looked at the file and the Plans rules. The file shows that the Plans dental benefit does not provide 
coverage for localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular 
tissue, per tooth (D4381). Therefore, we decided that the Plan does not have to pay for localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided 
on March 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 1, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the nursing home is responsible to 
obtain prior authorization for their patients, which should cover medical treatments by the provider. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the 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 a domiciliary or rest home visit provided on 
October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision of excessive skin of thigh. 
 
You asked the Plan to pre-approve the excision of excessive skin of thigh. You say that this is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the excision of excessive skin of thigh. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that you are a 47-year-old man who has had massive weight loss 
following gastric bypass surgery in 2012. The documentation is insufficient to demonstrate that excision of 
excessive skin from your thighs is medically reasonable and necessary in this case. The clinical record does not 
document what the enrollee's ambulation issues are. There is no documentation of chronic intertrigo that 
consistently recurs or is refractory to appropriate medical therapy over a period of 3 months. 
 
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 excision of excessive skin of thigh have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the excision of excessive skin of thigh.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services on February 17, 2022. 
 
You asked the Plan to pay for the radiology services. You say that you rely on the hospital personnel to obtain 
authorization. The Plan denied your request. The Plan says that the rendering provider is an OON provider and 
there was no approved authorization. 
 
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 claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the radiology services on February 
17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99203) provided by a 
chiropractor on February 8, 2022. 
 
You asked the Plan to pay for an office visit. You say that you do not have the money to pay the charges for the 
service at issue. The Plan denied your request. The Plan says the service at issue is not a covered benefit when 
billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office or other outpatient visit (99203) provided by a chiropractor on 
February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81210, 81206, 81235, and 
81194 provided on November 16, 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 billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The testing at issue in this appeal was being requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes.  
 
We find that CPT codes 81210, 81206, 81235, and 81194 are not supported in the medical record. Specifically, 
when a genomic sequencing procedure is completed, only one code should be billed. 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 coded 81210, 81206, 81235, and 81194 provided on November 
16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00731) provided on February 8, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that you have provided records to support the 
services at issue. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the case record does not explain why an anesthetist is not eligible to 
provide the services at issue. It is the Plan's responsibility to substantiate its denial. In this case, the denial has 
not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for 
anesthesia services (00731) provided on February 8, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 6 over-the-counter (OTC) coronavirus test kits purchased 
from January 3, 2022, to January 11, 2022. 
 
You asked the Plan to pay for the 6 OTC coronavirus test kits. You say that you heard that insurance would 
reimburse you for the OTC coronavirus test kits. You say that a plan representative advised they are covered. 
You also say that reimbursement was denied. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 6 OTC coronavirus test kits have not been met. Specifically, the file shows that the tests were 
purchased prior to January 15, 2022, when coverage started. Therefore, we decided that the Plan does not have 
to pay for the 6 over-the-counter (OTC) coronavirus test kits purchased from January 3, 2022, to January 11, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 1, 2021, to December 30, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not require daily skilled care on the dates of 
service in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from December 1, 2021, to December 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neuromonitoring (code G0453) 
provided on July 27, 201. 
 
You asked the Plan to pay for continuous intraoperative neuromonitoring. You say that this is medically 
necessary and covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code G0453 has a procedure-to-procedure (PTP) edit value of 1 with code 95812 so is not 
separately payable under the circumstances. 
 
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 G0453 
is a column II code to column I code 95812. 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 continuous intraoperative neuromonitoring (code G0453) 
provided on July 27, 201.