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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. 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 February 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to be reimbursed for the powered pressure-reducing air mattress 
(E0277) purchased on October 16, 2019, by an out-of-network (OON) provider. 
 
You asked the Plan to be reimbursed for the mattress. You say that you need the air mattress to lay comfortably 
due to severe psoriasis. This should be covered by the Plan because you had a referral from your primary care 
provider to receive this mattress. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before 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 be reimbursed for the powered pressure-reducing air 
mattress (E0277) purchased on October 16, 2019, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of SNF care from October 28, 2022, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing needs. You do not have documented 
skilled therapy needs. Daily skilled services are not shown to be 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 the continuation of SNF care from October 28, 2022, forward.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 29, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member was enrolled in hospice in July 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on July 20, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility 
care provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on April 21, 
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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the location of services must be reported 
correctly.  
 
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. Specifically, this claim was billed with the outpatient POS code, 
even though the enrollee was inpatient at this time. Therefore, we decided that the Plan does not have to pay for 
radiology services provided to the enrollee on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0037U provided on March 7, 2022. 
 
You asked the Plan to pay for procedure code 0037U. 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 to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 procedure code 
0037U provided on March 7, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 44620) provided to the enrollee on 
January 4, 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 denied code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 supported by the medical records. Our physician reviewer found that the 
enrollee nderwent a sigmoid colectomy with coloproctostomy after takedown of a colostomy. The patient 
underwent a separate colostomy site removal and closure. This is considered a separate but related procedure 
with secondary modifier code as it was separate and distinct but secondary to the primary colectomy. It is 
considered additional work as it would not have been required in the setting of a colectomy in someone without 
a colostomy. The enterostomy closure is a separate procedure with secondary modifier. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 44620) provided to the enrollee on January 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Percepta Bronchial Genomic Classifier (81479) provided 
June 3, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the results of the Percepta test enabled the 
doctor to move forward with determining the safest and most effective course of treatment for the enrollee. The 
Plan denied your request. The Plan says the enrollee did not meet the requirements for approval and the request 
is not medically necessary. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a diagnosis of solitary pulmonary nodule. 
The record sent by the provider indicates that the enrollee was a smoker, had lung abnormalities on PET/CT 
scan on May 19, 2021, and underwent a bronchoscopy on May 21, 2021, with a physician-assessed high pretest 
risk of malignancy. The pathology report showed metastatic melanoma. In this case, the request is not 
medically necessary because the records show that the enrollee had a physician-assessed high pretest risk of 
malignancy and the bronchoscopy was diagnostic with a malignant diagnosis. The review has determined that 
the medical records provided do not meet medically necessary requirements listed in the LCD for Medicare 
coverage. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for Percepta Bronchial Genomic Classifier (81479) provided June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code a6533 that 
were issued on May 16, 2022. 
 You asked the Plan to pay for the compression stockings. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says this is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code a6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code a6533 that were issued on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on July 18, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says that the eye 
refraction will remain denied due to it not being a covered benefit when it is being performed for medical 
reasons, such as determining the Type 2 diabetes mellitus without complications. Eye refractions are only 
covered by your Plan if performed by a participating vision provider and performed as a routine screening. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file, the Plans rules and the Medicare rules. Medicare does not pay for procedures performed 
in the course of any eye exam to determine the refractive state of the eyes. The Plan covers eye refractions only 
when performed by a participating vision provider and performed as a routine screening. The file shows that 
you received they eye refraction for a medical diagnosis of Type 2 diabetes mellitus without complications. 
Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 18, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prescription drug, Synthroid 100mcg tab. 
 
You asked the Plan to pre-approve a prescription drug. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this medication falls under the pharmacy (drug) benefit and the enrollee 
does have a pharmacy benefit administered by the plan. Drugs covered under pharmacy benefit are not eligible 
for coverage under Part B benefit. 
 
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. Your Medicare advantage plan does not cover outpatient prescription drugs. You may have a 
separate commercial pharmacy benefit or Medicare Part D benefit. Therefore, we decided that the Plan does not 
have to pre-approve a prescription drug, Synthroid 100mcg tab.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 18, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical information indicates transportation other than an ambulance could have 
been utilized. 
 
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 on 1/20/2022. 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. 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 18, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the cost-share for diagnostic imaging provided on June 7, 2022. 
 
You asked the Plan to waive the cost-share for diagnostic imaging. You say that you are appealing the invoice 
received in the amount of $7,293.19. You say that you reviewed the summary of benefits for your Plan and are 
unable to locate the justification for the amount billed. The Plan denied your request. The Plan says that the 
cost-share applied is correct. 
 
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 did not submit an Explanation of Benefits or claim form confirming 
what services were billed. The Plan also did not submit documentation showing the allowed amount of each 
service billed. This means that we cannot determine the cost you are being asked to pay is correct or justified 
by the contract. Therefore, we decided that the Plan has to waive the cost-share for diagnostic imaging 
provided on June 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that the specimens received are from providers who 
have performed intra-operative procedural biopsies, health care facilities and medical practices and the 
specimens are irreplaceable, not reproducible and must be processed without delay to avoid spoilage. 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 April 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for noncovered item or service, turban (A9270) and 
noncovered item or service, grab bar (A9270) purchased on February 28, 2022 to April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to reimburse you for the turbans and grab bar. You say that you feel that the reimbursement 
should be processed. You did not know that over-the-counter durable medical equipment needed to be in 
network. The Plan denied your request. The Plan says these items are not covered by Medicare. Enrollees 
must receive their medical services from an in-network provider. Non-emergent services with non-contracted 
providers require prior authorization before 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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. The rules say that for equipment to be covered, it 
must primarily serve a medical purpose.   
 
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. The item at issue in this appeal does not serve a purpose that is primarily medical in 
nature. This item is available to the general public and would be helpful even to those who are not sick or 
injured. We found no exception that would require the Plan to reimburse you for these items/services. 
Therefore, we decided that the Plan does not have to reimburse you for noncovered item or service, turban 
(A9270) and noncovered item or service, grab bar (A9270) purchased on February 28, 2022 to April 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the claim submitted is a direct result of services 
rendered by another provider. You say that you are requesting the claim be reprocessed and paid. The Plan 
denied your request. The Plan says an authorization was not obtained prior to services 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 laboratory services provided on February 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 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 May 26, 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 these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing rendered on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable gaseous oxygen system, rental (E0431) portable 
oxygen concentrator (E1390) provided March 19, 2022 to April 19, 2022. 
 
You asked the Plan to pay for the oxygen supplies. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or an itemized shipping/billing invoice to indicate the specific supplies for the supplies provided in this case. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the portable gaseous oxygen system, rental (E0431) portable oxygen concentrator (E1390) provided March 
19, 2022 to April 19, 2022.