Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home infusion therapy (S9328) provided on September 10, 2022, to 
October 7, 2022. 
 
You asked the Plan to pay for the home infusion therapy. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that the services denied correctly as the 
rendering provider is not a participating provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the home infusion therapy by a contract provider. The file does not show that the Plan 
provided notice that the home infusion therapy would not be covered. Under Medicare rules, this means the 
home infusion therapy is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
the home infusion therapy (S9328) provided on September 10, 2022, to October 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73630 and 73610 billed for September 1, 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure codes 73630 and 73610 have an OPPS status 
indicator of Q1(s) and were billed with code 99284, which has an OPPS status indicator of V. Codes 73630 and 
73610 are not separately payable when billed with a code with an OPPS status indicator of V. Therefore, we 
decided that the Plan does not have to pay for procedure codes 73630 and 73610 billed for September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for September 16, 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 99223 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 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 these services. Our reviewer says that procedure code 99223 
is not supported. Our reviewer found the records do not document medical decision making of high 
complexity. The records report admission to the hospital with severe anemia with a hemoglobin level of 3.8 
grams/dL with no symptoms except "very mild" fatigue and generalized weakness. The reviewed data included 
standard blood tests, including a complete blood count, complete metabolic panel and coagulation studies and a 
portable chest radiograph. The records do not support the billing of code 99223. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for September 16, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on May 14, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the service should be covered. The 
Plan denied your request. The Plan says this claim was filed untimely. 
 
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 emergency room services was not filed until October 19, 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 emergency room services provided on May 14, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing provided on October 5, 2022. 
 
You asked the Plan to pay for SelectMDx genetic testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable 
and necessary and covered nationally when the criteria listed in the Medicare rules section of this letter have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met.  Specifically, we determined that SelectMDx genetic 
testing does not have FDA clearance. Therefore, we decided that the Plan does not have to pay for SelectMDx 
genetic testing provided on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology, MI profile (81479) 
provided September 24, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the in-network physician had ordered these 
services despite your status as an out of network provider and determined these results of these services are 
medically necessary to provide the best care for the enrollee. The Plan denied your request. The Plan says the 
records do not show that the enrollee meets the Medicare NCD criteria. 
 
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 reviewed documentation indicates that the enrollee has a diagnosis of malignant 
neoplasm of middle lobe, bronchus or lung (C34.2). The enrollee had stage IIA non-small cell lung cancer post 
lobectomy. The provider was planning treatment with Carboplatin-Pemetrexed. Per National Comprehensive 
Cancer Network (NCCN) guidelines for non-small cell lung cancer version 1.2023 says treatment for stage IIA 
cancer with negative margins incudes chemotherapy followed by Atezolizumab or Osimertinib (EGFR exon 19 
deletion or exon 21 L858R). In addition, per Centers for Medicare and Medicaid services (CMS) guidelines 
NCD 90.2, for the requested test the patient should have recurrent, relapsed, refractory, metastatic or advanced 
stage III or IV cancer to meet criteria. The review has determined that the items/services at issue in this case are 
not medically reasonable or necessary. 
 
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 the unlisted molecular pathology, MI profile (81479) provided September 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the private duty nursing (T1000). 
 
You asked the Plan to pre-approve the private duty nursing. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the private duty nursing have not been met. The rules say that the 
services of a private-duty nurse or other private-duty attendant are not covered. Therefore, we decided that the 
Plan does not have to pre-approve the private duty nursing (T1000).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74150 billed for date of service November 
13, 2022. 
 
You asked the Plan to pay for procedure code 74150. You say that the claim is billed correctly and should be 
paid The Plan denied your request. The Plan says payment for code 74150 is bundled into payment for code 
74174. 
 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 74150 
is a column II code to column I code 74174. 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 74150 billed for date of service November 13, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation services to a non-primary 
care doctor. 
 
You asked the Plan to pre-approve non-emergency transportation services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says transportation to other specialist 
appointments other than to your primary care doctor is not covered and is denied. 
 
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.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Your benefit only allows for 
unlimited rides to your primary care provider's (PCP's) office. Your request for non-emergent transportation to 
locations other than the PCPs office under the supplemental transportation benefit is not covered. There is no 
exception that would allow the plan to approve transportation to non-PCP locations. Therefore, we decided that 
the Plan does not have to pre-approve non-emergency transportation services to a non-primary care doctor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0553) provided on 
August 10, 2022. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the date of service billed on this claim does not match the 
shipping date or the date or delivery. 
 
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 to support medical necessity for the supplies provided in 
this case. The record shows that the shipping date of this item was August 5, 2022, and the delivery date was 
August 8, 2022. Therefore, the date of service billed on this claim, August 10, 2022, does not meet Medicare 
rules. 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 a continuous glucose monitor (CGM) 
(K0553) provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6212, A6010) provided on November 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the provider is not a network provider. The services were not urgent or 
emergent, nor were they approved in advance. 
 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 wound care supplies (A6212, A6010) provided on 
November 11, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room evaluation and management (E&M) visit provided 
on September 6, 2022. 
 
You asked the Plan to pay for emergency room E&M visit. You say that this code is supported with a modifier 
indicating separate supporting diagnosis for this procedure. The Plan denied your request. The Plan says that 
this code is included when billed within the global surgery period of minor surgery procedure 10160 without an 
appropriate modifier. 
 
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 rules say that code 10160 has a Global Surgery indicator of 010 meaning evaluation and 
management services on the day of the procedure and during the 10-day postoperative period are not generally 
payable. 
 
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 states that code 99284 is not payable within the Global Surgery period 
of code 10160 without an appropriate modifier. However, code 99284 was billed with modifier -25 indicating a 
significant, separately identifiable evaluation and management service. While the rules state that E&M services 
are not generally payable on the day of procedure 10160, or within the 10-day postoperative period, the rules 
do not state that E&M services are excluded from payment within this Global Surgery period. The Plan has not 
stated that modifier -25 is inappropriate in this application, nor has the Plan shown that code 99284 should still 
be excluded from payment despite the use of modifier -25. Therefore, the Plan has not shown that its decision 
to deny payment for this service is correct or justified according to Medicare billing and coding guidelines. 
Therefore, we decided that the Plan has to pay for an emergency room evaluation and management (E&M) 
visit provided on September 6, 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 the CXbladder detect test (0012M) provided on October 5, 
2022. 
 
You asked the Plan to pay for the CXbladder detect test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory infection panel (87502, 87532, 87541, 87581, 
87640, 87651, 87798, U0004 and U0005) provided on September 12, 2022. 
 
You asked the Plan to pay for the respiratory infection panel. You say that this test is supported in the medical 
record and should be paid. The Plan denied your request. The Plan says this panel was not billed in accordance 
with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. Therefore, we decided that the Plan does not have to pay for the respiratory infection panel (87502, 87532, 
87541, 87581, 87640, 87651, 87798, U0004 and U0005) provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoglobulin light chain test (83521) provided June 2, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that this same test was analyzed in 2021 and 
there were no issues and the Plan paid the claim submitted by the provider. You were told by the provider's 
office that the claims are now being resubmitted to the Plan this time with a correct code. The Plan denied your 
request. The Plan says this service is considered experimental and investigational and is not covered. 
 
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. 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 immunoglobulin light chain test (83521) provided June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided from January 14, 2022, to 
November 14, 2022. 
 
You asked the Plan to pay for incontinence supplies. You say that you have not received a bill for these 
supplies. You also say that you feel you should not be held responsible for these charges. The Plan denied your 
request. The Plan says the supplies are not eligible for payment through your medical plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided from 
January 14, 2022, to November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
September 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was rendered to the enrollee in 
good faith. You also say that the provider relies on the facility to obtain the necessary authorizations. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 items/services. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
September 7, 2022, 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 January 19, 2021. 
 
You asked the Plan to pay for the physician's services. You say that you depend on the facility for timely 
notification of the patients health insurance coverage. You say your physician provided medically necessary 
services to the member in good faith. The Plan denied your request. The Plan says the claim was untimely, and 
the submission did not meet the exception criteria guidelines outlined in the Medicare Claims Processing 
Manual Chapter 1 Sections 70.1 and 70.4. 
 
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 physician's services. was not filed until December 2, 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 physician's services provided on January 19, 2021.