Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A6198, A6199, A6212, A6253) provided on 
March 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "P" under the Physician Fee 
Schedule indicates that there are no RVUs and no payment amounts for these services.  
 
We looked at the file and Medicare rules. Codes A6198, A6199, A6212, and A6253 are assigned a status 
indicator of B under the Physician Fee Schedule, which means that these are bundled services. Separate 
payment cannot be made for these services. 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 (A6198, A6199, A6212, A6253) provided on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical records were not received. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the case file does not contain clinical documentation that supports the medical necessity of the 
laboratory services provided. 
 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 laboratory services provided to the enrollee on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the analysis is now a standard of care. The 
Plan denied your request. The Plan says the rules for payment of the billed code have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. An independent laboratory may not bill the Medicare for the technical 
component of a physician pathology service furnished to a hospital inpatient or outpatient. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on December 20, 2020. 
 
You asked the Plan to pay for the services provided. You say that the technical component of the procedure 
was performed by your technician. The Plan denied your request. The Plan says the code must be billed by the 
skilled nursing facility. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that the enrollee received x-ray services while in a skilled 
nursing facility. The facility must bill radiology services furnished to its inpatients. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the chest x-ray provided on December 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three periodontal maintenance's (D4910 x3), core 
buildup, including any pins when required (D2950), re-cement or re-bond crown (D2920), problem focused 
limited oral evaluation (D0140), localized delivery of antimicrobial agents (D4381), two periodic oral 
evaluations (D0120 x2), resin-based composite (D2394), crown (D2740), complete series of intraoral x-rays 
(D0210), and first intraoral periapical x-ray (D0220) provided from April 13, 2021, to November 30, 2021 by 
an out-of-network (OON) provider.  
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says periodontal 
maintenance, core buildup, re-cement or re-bond crown, problem focused limited oral evaluation, and localized 
delivery of antimicrobial agents are not covered. The Plan also says that services performed by an OON 
provider are not covered because your healthcare plan does not have OON benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance (D4910), 
core buildup, including any pins when required (D2950), re-cement or re-bond crown (D2920), problem 
focused limited oral evaluation (D0140), and localized delivery of antimicrobial agents (D4381) are not among 
those covered under this benefit. The contract also says that you are responsible for 100% of the cost for dental 
services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the three 
periodontal maintenance's (D4910 x3), core buildup, including any pins when required (D2950), re-cement or 
re-bond crown (D2920), problem focused limited oral evaluation (D0140), localized delivery of antimicrobial 
agents (D4381), two periodic oral evaluations (D0120 x2), resin-based composite (D2394), crown (D2740), 
complete series of intraoral x-rays (D0210), and first intraoral periapical x-ray (D0220) provided from April 
13, 2021, to November 30, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on December 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service has already 
been paid. 
 The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (71045) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second medial branch block (MBB). 
 
You asked the Plan to pre-approve a second MBB. You say that this procedure is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage for 
the second MBB have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients when, after the first diagnostic facet 
joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain 
 
We looked at the file and Medicare rules. In this case, the documentation does not confirm that the enrollee had 
at least 80% relief of primary pain after the first injection procedure. Based on this information, we decided 
that Medicare rules for coverage of a second MBB have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a second medial branch block (MBB).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
November 20, 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 there is no valid order. 
 The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on November 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
August 27, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that this service is supported as 
billed. The Plan denied your request. The Plan says this service is not supported in the record. 
 
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 99239 is hospital discharge day management; more than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. Based on this information, we decided that Medicare rules for coverage of 
hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to 
pay for hospital discharge day management (99239) provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the RoWheels wheel set purchased on July 23, 2021. 
 You asked the Plan to pay for the RoWheels wheel set. You say that you would like reconsideration because 
you need this equipment to safely get around your home and property. The Plan denied your request. The Plan 
says you do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also say that specific criteria must be met for the coverage of the 
requested wheels. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Additionally, the record submitted does not 
show that you have had a specialty evaluation that was performed by a licensed/certified medical professional 
that documents the need for the device in your home or that the wheels were provided by a supplier that 
employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who 
has direct, in-person involvement in the wheelchair selection. Therefore, we decided that the Plan does not 
have to pay for the RoWheels wheel set purchased on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 the lab services provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 23, 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 laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on December 19, 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 are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, 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 the computed tomography (CT) scan of the head/brain rendered 
on December 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical trays rendered on October 28, 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 are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4550 has a status indicator of B on the Physician Fee Schedule. This means that CPT code A4550 is not separately payable. 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 surgical 
trays rendered on October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that the test enables confident treatment 
decisions. The Plan denied your request. The Plan says the lab was not credited to perform the lab work. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. The records show that the lab CLIA certificate was not in effect at the time 
the services were provided. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing services provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve evaluation services. You say that you have seen multiple providers without 
success. The Plan denied your request. The Plan says there are in-network providers available to meet your 
medical needs. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
evaluation services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a debridement procedure provided on November 23, 
2021. 
 
You asked the Plan to waive the copayment for a debridement procedure. You say that you were surprised 
when the provider billed you for a debridement procedure which never occurred. The Plan denied your request. 
The Plan says that you have been charged the correct cost sharing amount. 
 
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 provide medical records to show what services were rendered 
during your visit. Without the medical records we are unable to confirm what services did or did not take place 
and cannot determine if cost sharing applies. Therefore, we decided that the Plan has to waive the copayment 
for a debridement procedure provided on November 23, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp for the enrollee. 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not being requested for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary. The enrollee has a diagnosis of anemia in the setting of 
stage 3B chronic kidney disease. The record indicates that the enrollee has a hemoglobin of 11.7 and the use of 
the requested drug is to improve exercise tolerance. The Food and Drug Administration has stated that 
improvement in quality of life, fatigue, or patient well-being has not been shown. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of Aranesp. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided on April 5, 2021, and 
April 6, 2021. 
 
You asked the Plan to pay for the home health care services. You say that this claim needs to be reprocessed 
for the correct reimbursement. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the RAP claim for services for date of service April 5, 2021, to April 6, 2021 until April 26, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided on April 5, 2021, and April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 13, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
 
 
 
 We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81206, 81162, 81292, 
81295, 81298, 81301, 81311, 81317, 81194 and 81309 provided February 16, 2021. 
 
You asked the Plan to pay for the laboratory service. 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. Medicare rules say that 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 laboratory service 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. the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an Office setting POS 11. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 81206, 81162, 
81292, 81295, 81298, 81301, 81311, 81317, 81194 and 81309 provided February 16, 2021.