Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the medical eye exam (92014) provided on December 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that the provider's office contacted the Plan, and 
advised you that you would be responsible for a $25 copay for the specialist visit. The Plan denied your 
request. The Plan says that this vision service is not covered. 
 
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 Plan denied this service saying it is not covered. However, 
according to the 2021 Evidence of Coverage, outpatient physician services for the diagnosis and treatment of 
diseases and injuries of the eye, including treatment for age-related macular degeneration is covered by the 
Plan. The contract also says that you are responsible for a 20% coinsurance when the service is received OON. 
The Plan has not supported their denial of payment in this case. Therefore, we decided that the Plan has to pay 
for the medical eye exam (92014) provided on December 9, 2021, by an out-of-network (OON) provider.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97110) provided on September 15, 
2021. 
 
You asked the Plan to pay for the therapy 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 services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services (97110) provided on 
September 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on August 11, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that the claim was not submitted with a required RAP. 
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 home health services rendered on August 11, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on September 17, 
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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on September 17, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management rendered on July 1, 
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 the enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management rendered on July 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81479, 
81407, 81408, and 81404) provided on March 7, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that this testing 
was medically necessary. The Plan denied your request. The Plan says screening genetic testing is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: code 80061 (Lipid panel) which includes codes: 82465 (Cholesterol, serum 
or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol), and/or 84478 
(Triglycerides). 
 
We looked at the file and Medicare rules. The codes billed are non-covered for screening purposes. Based on 
this information, we decided that Medicare rules for coverage of the cardiac risk assessment genetic screening 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiac risk 
assessment genetic screening testing (81479, 81407, 81408, and 81404) provided on March 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for care giving services provided from April 10, 2022, to 
May 27, 2022. 
 
You asked the Plan to pay for care giving services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says custodial care is not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of care giving services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for care giving 
services provided from April 10, 2022, to May 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that this claim has been billed with an 
inappropriate date of service. 
 
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 case file does not show that the lab service does not meet any of the exceptions outlined in the Medicare 
ruling. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request.  Therefore, we decided that the Plan has to pay for the laboratory services 
provided on May 19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator (E1390) purchased June 27, 
2022. 
 
You asked the Plan to pay for the oxygen supplies. You say that you are appealing the denial of the request for 
reimbursement for the purchased supplemental oxygen equipment. The Plan denied your request. The Plan says 
only rented oxygen equipment is eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered. Based on 
this information, we decided that Medicare rules for coverage of the oxygen supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator (E1390) purchased 
June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88112, 88305, 88312, and 88361 billed for 
date of service December 22, 2021. 
 You asked the Plan to pay for procedure codes 88112, 88305, 88312, and 88361. You say that you disagree 
with the denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88112, 88305, 88312, and 88361 have a Professional/Technical indicator of 1. This 
means that CPT codes 88112, 88305, 88312, and 88361 have both a professional and technical component. In 
this case, CPT code 88112, 88305, 88312, and 88361 has not been billed with an appropriate modifier to 
indicate the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88112, 88305, 88312, and 88361 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88112, 88305, 88312, and 88361 billed for date of service December 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 14, 2022 billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81335, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the claim was not billed correctly. 
 
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 
February 14, 2022 billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 
81328, 81335, and 81355.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services rendered on May 8, 2020. 
 
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 97530 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for the services. 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 occupational therapy services rendered on May 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Morphometric analysis, tumor immunohistochemistry (eg, 
Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody (88360) 
provided January 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are in independent laboratory that 
provides molecular diagnostic services to cancer patients. The Plan denied your request. The Plan says 
Medicare procedure requires modifier 26. 
 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 find that CPT code 88360 is not supported in the medical record. Specifically, the billed 
procedure code 88360 has a physician Fee Schedule PCTC indicator of 1 and the claim a POS of 21- Inpatient 
hospital. As per review, the provider is an independent laboratory (81) but the claim was billed with place of 
service "21" and the claim was billed incorrectly without modifier "26". 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. 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 Morphometric analysis, tumor 
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or 
semiquantitative, each antibody (88360) provided January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (0238T, 37220, 37227, 37252, 37253, 
75710, 99152, 99153, J2250, J3010, J3360) provided on March 29, 2022. 
 
You asked the Plan to pay for radiology services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 2, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (0238T, 37220, 37227, 37252, 37253, 
75710, 99152, 99153, J2250, J3010, J3360) provided on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema and inflammation and post-surgical lymphedema. You disagree with this denial and believe 
these services were medically necessary. The Plan denied your request. The Plan says pneumatic compression 
device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from October 25, 2021, to November 
17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the RAP claim was not 
filed within 5 days. 
 
The Plan must follow Medicare rules. Medicare rules say that a timely-filed RAP is submitted to the A/B MAC 
(HHH) and accepted by the contractor within 5 calendar days after the From date of a HH period of care.  
 
We looked at the file and Medicare rules. The RAP claim in this case was not submitted with 5 calendar days 
after the From date of a home health period of care. 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 the 
services provided from October 25, 2021, to November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360) provided on January 11, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88341, 88342, & 88360 are not supported in the medical record. Specifically, the 
codes billed have a professional component / technical component of 1. The enrollee was a patient in a facility 
at the time the services were provided. The interpretation must be separately billed by the physician with 
modifier 26. 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 (88341, 88342, 88360) 
provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme testing provided on March 15, 
2022. 
 
You asked the Plan to pay for the FoundationOne Heme testing. You say that this test was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the FoundationOne Heme test is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the FoundationOne Heme 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne 
Heme testing provided on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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, for 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 lab services provided on January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 15, 
2022. 
 
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 that the clinical indicates transportation other than an ambulance (e.g., private car, wheelchair 
van, etc.) could be utilized without endangering the individual's health, whether or not such other transportation 
is actually available. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this patient. The documentation does not support 
that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide for safe transport on 1/20/2022. The documentation does not support that the 
ambulance transport on 1/20/2022 was medically reasonable and necessary for the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on January 15, 2022.