Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you choose this turquoise wheelchair 
from the booklet of wheelchairs. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the power wheelchair at issue in this appeal. We found no exception that would 
require the Plan to pre-approve the power wheelchair. Therefore, we decided that the Plan does not have to pre-
approve the power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); including recording awake and 
asleep (95819) billed for dates of service September 12, 2021, and September 17, 2021. 
 
You asked the Plan to pay for procedure code 95819. You say that these services were billed appropriately and 
are supported in the record. The Plan denied your request. The Plan says these services are not supported as 
billed and are missing a modifier which is required for processing. 
 
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 95819 is electroencephalogram (EEG); including 
recording awake and asleep. 
 
We asked our coder 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 procedure code 95819. Our reviewer says that the 
documentation provided does not support the services billed. Our reviewer found the medical record includes 
an EEG interpretation report but does not include a technical report of the procedure performed. Per CPT 
guidelines, "Routine EEG codes 95816-95822 include 20 to 40 minutes of recording. Extended EEG codes 95812-95813 include reporting times longer than 40 minutes". In this case, time is not documented; therefore 
the correct CPT code cannot be verified. In addition, the service was billed for inpatient hospital facility (Place 
of Service 21). Code 95819 has a Professional Component (PC)/Technical Component (TC) Indicator of 1, 
which means that 95819 has both a technical and professional component. These services were billed with no 
modifier, which indicates that payment for both components is requested. However, the technical component is 
reimbursed to the facility in this case, so the TC modifier would not be supported and the appropriate 
professional component only modifier must be used. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95819 have not been met. Therefore, we decided that the Plan 
does not have to pay for electroencephalogram (EEG); including recording awake and asleep (95819) billed for 
dates of service September 12, 2021, and September 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like additional trips to be 
approved for coverage so you can attend an appointment. The Plan denied your request. The Plan says you 
have used ten one-way trips to Plan approved facilities for the year 2022. The Plan also says that additional 
trips in excess of ten one-way trips are not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 10 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you need additional transportation 
for dialysis. You also say that you need this benefit extended so you can go to your appointments. The Plan 
denied your request. The Plan says you have used the 30 one-way trips that are covered by your plan for the 
year 2022. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 30 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 18, 2021. 
 
You asked the Plan to pay for the services provided. You say that you are not subject to the Plan's filing 
limitations. The Plan denied your request. The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until January 26, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on January 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy visits provided on 
September 17, 2021, to September 29, 2021. 
 
You asked the Plan to waive the coinsurance for physical therapy. You say that you should not have a charge 
for these visits. The Plan denied your request. The Plan says the coinsurance 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 $47.36 
coinsurance for outpatient rehabilitation services.  
 
You have been asked to pay $47.36 coinsurance for physical therapy. Physical therapy falls 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 coinsurance for 
physical therapy visits provided on September 17, 2021, to September 29, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan 
requires a trial of oral bisphosphonates or intravenous bisphosphonates such as Reclast before it will approve 
Prolia. 
 
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 Prolia. Our reviewer says that the 
enrollee meets the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Reclast. However, there is concern that Reclast 
may have adverse effects for the enrollee. The enrollee is reported to be aspirin-allergic, and the reported 
history of air hunger after taking Fosamax is concerning for a possible class effect with other bisphosphonates. 
The possibility of a serious respiratory side effect of another bisphosphonate is of sufficient concern for an 
exception to the Plan's step therapy criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
use of Prolia.  
 
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 genetic testing provided on November 13, 2020, billed 
with codes 81407, 81405, 81404, 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services have not been billed 
correctly based on Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 13, 2020, billed with codes 81407, 81405, 81404, 81406.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug test of 22 or more drug classes (G0483) 
provided February 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please find enclosed the documents to 
support the billing of G0483. The Plan denied your request. The Plan says the documentation submitted does 
not meet the coding criteria and does not support 22 or more drug classes. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays and enzymatic methods (e.g., alcohol dehydrogenase)), (2) 
stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
We asked our coder 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 laboratory services. Our reviewer says that the laboratory 
services do not meet the criteria for coverage. Our reviewer found the documentation submitted was reviewed 
and does not meet criteria. Laboratory report does not support 22 or more drug classes tested. There is a more 
appropriate code to report to support 18 classes documented. 
 
We looked at this coder's review, the file, and Medicare rules. 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 definitive drug test of 22 or more drug classes (G0483) provided February 23, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you need more rides to get to your 
appointments. You also say that you live alone and do not have family to assist you. The Plan denied your 
request. The Plan says the Evidence of Coverage clearly states you have 100 one-way trips per calendar year, 
the 101st and beyond is not a covered benefit. The Plan also says you have used 68 trips and have 32 trips 
remaining in 2022. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 100 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, this request 
will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve additional transportation (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the testing services. You say that sufficient in-network provider options were 
unavailable. The Plan denied your request. The Plan says genetic testing requires benefit certification. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on August 3, 2021, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 10, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under open access unless preauthorized. 
 
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 
services 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 physician's services provided on March 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued SNF services after August 3, 2022. 
 
You asked the Plan to pay for continued SNF. You say that the enrollee needs continued SNF care. The Plan 
denied your request. The Plan says rules for continued SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 25, 2022, 
to August 3, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for continued SNF services after August 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 21, 2021, to April 
25, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 193 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee with a history of schizophrenia, 
hypertension, emphysema, and Burkett's lymphoma, presented for evaluation on April 21, 2021, from his 
Primary Care Physician's office due to reported fatigue, hypotension, hyponatremia and white blood cell count 
elevation. The emergency department physician described the enrollee as having been alert and oriented to 
person, place and time and in no acute distress. The enrollee was admitted for further evaluation and 
management, receiving intravenous fluids and empiric intravenous antibiotics. Image-guided biopsy of a right 
lung lesion was performed on April 22, 2021; cytology returned with a finding of poorly differentiated non-
small cell carcinoma with extensive necrosis. The enrollee was continued on intravenous antibiotics for 
suspected post-obstructive pneumonia. The enrollee was discharged to complete a course of oral antibiotics. 
There was no clinical or laboratory evidence of sepsis. The review has determined that the medical records did 
not support the billing of sepsis, unspecified organism (A41.9). 
 
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 care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 21, 2021, to April 25, 2021, 
as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says these laboratory tests are included in the 
dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
23, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you have diabetes so this 
should be covered. 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 $40 
copayment for each Medicare-covered visit.  
 
You have been asked to pay $40 copayment for specialist office visit. Specialist office visits fall within the 
Podiatry Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist office visit 
provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 9, 2021, billed with 
codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81309, 81310, 81311, 
81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed appropriately 
per Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 9, 2021, billed with codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 
81293, 81309, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406.