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

 
We decided that the Plan has to pre-approve an Esophagogastroduodenoscopy. 
 
You asked the Plan to pre-approve an Esophagogastroduodenoscopy. You say that an 
Esophagogastroduodenoscopy is medically necessary. The Plan denied your request. The Plan says that an 
Esophagogastroduodenoscopy does not meet the Plan's Medical Policy coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 an Esophagogastroduodenoscopy. Our 
reviewer says that an Esophagogastroduodenoscopy is considered medically reasonable and necessary in this 
case. Our physician reviewer found that the evidence in the medical literature at this time supports that this 
procedure is safe and improves symptoms and quality of life in post patients with continued gastroesophageal 
reflux disease symptoms despite medical management with proton pump inhibitors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Esophagogastroduodenoscopy have been met. Therefore, we decided that the 
Plan has to pre-approve an Esophagogastroduodenoscopy.  
 
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 laboratory services coded 81206, 81210, 81235, 81275, 
81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, and 81309 provided on November 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 
81194, and 81309 are not supported in the medical record. Specifically, when a laboratory assays two or more 
genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel 
constitutes one single procedure, so one code should be submitted for the entire panel. Review of the file does 
not support that only one code was billed for the panel provided. 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 laboratory services coded 81206, 81210, 81235, 81275, 81276, 81292, 81295, 
81298, 81301, 81317, 81401, 81194, and 81309 provided on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the CTA provided on January 31, 2022. 
 
You asked the Plan to waive the deductible for the CTA. You say that you paid the doctor copayment of $40 
and CT scan copayment for $300. You say that these are surprise out-of-network billings and you don't know 
why you are receiving the bill. The Plan denied your request. The Plan says the deductible applied correctly to 
the out-of-network physician claim for the CTA. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to the CTA.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to out-of-network services. This cost 
sharing is a contractual obligation that had not been met at the time the CTA was received on January 31, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the CTA provided on January 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on January 26, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services were not urgent or emergent. 
 
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 an electrocardiogram (ECG) provided on January 
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 lab services (81206, 81292, 81301) provided April 28, 2021. 
 
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 a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81206, 81292, 81301) provided April 
28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that services should be paid by the Plan. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no referral 
from an in-network provider or an approved authorization. Also, the service rendered was not urgent or 
emergent. 
 
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 the chiropractic services provided on February 4, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $16.33 deductible for an electrocardiogram performed on 
March 18, 2022. 
 
You asked the Plan to waive the $16.33 deductible for an electrocardiogram performed on March 18, 2022. 
You say that you should not be responsible for this cost share as you usually have this test covered in the 
doctor's visit. The Plan denied your request. The Plan says you must pay $16.33. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
The item or service you asked the Plan to waive the $16.63 deductible for falls within the benefit category 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $250 deductible which applies to Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time an electrocardiogram was performed on March 18, 2022. Therefore, we decided that the Plan does not 
have to waive the $16.33 deductible for an electrocardiogram performed on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 2, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
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 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 drug testing 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 drug testing coded G0483 provided on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is presently receiving these services in the short-term acute care setting. 
Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a 
lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled 
nursing facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the outpatient surgery services you received on January 5, 
2022. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for outpatient surgery in an outpatient hospital facility.  
 
Review of the file shows that you received outpatient surgery services on January 5, 2022. Per your contract 
with the Plan, there is a $400 copayment for outpatient surgery. This cost sharing is a contractual obligation 
that you agreed to pay when you enrolled in plan name. However, the Medicare allowed amount for these 
services was less than the $400 copayment. Given that the allowed amount was less than the $400 copayment, 
you have been asked to pay the lesser amount. Therefore, we decided that the Plan does not have to waive the 
outpatient surgery services you received on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on October 7, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered for 
screening. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00812) provided January 29, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the 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 anesthesia services was not filed until February 28, 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 anesthesia services (00812) provided January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement services coded 36217, 
36222, and 36218 provided on June 18, 2021. 
 
You asked the Plan to pay for the selective catheter placement services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 36217 and 36222 are not supported in the medical record. Specifically, the services 
were performed on the ipsilateral carotid territory. The documentation states that procedures identified with 
codes 36217 and 36223 were performed during the same session. Only the code that represents the most 
comprehensive service should be reimbursed. In this case, we have confirmed that code 36218 is an add-on 
code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, 
Medicare billing criteria have not been met. 
 
Based on this information, we decided that Medicare rules for coverage of the selective catheter placement 
services have not been met. Therefore, we decided that the Plan does not have to pay for the selective catheter 
placement services coded 36217, 36222, and 36218 provided on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits on February 26, 2022, to 
March 7, 2022. 
 
You asked the Plan to waive the copayments for office visits. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayments applied are correct. The amount charged is 
less than the $150 for three urgent care visits because the provider acknowledged that they wrote off the 
member cost for March 7, 2022. The total cost share owed is $74.01. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 for 
each Medicare-covered urgent care facility visit. This copayment is not waived if you are admitted as an 
inpatient to the hospital within 24 hours for the same condition. for office visits.  
 
 You have been asked to pay a $50 for each Medicare-covered urgent care facility visit. This copayment is not 
waived if you are admitted as an inpatient to the hospital within 24 hours for the same condition. Office visits 
fall within the Urgently needed services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for office visits on February 26, 2022, to March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided on February 23, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a sleep study. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 a sleep study provided on February 23, 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 anesthesia services (99100) provided May 3, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for payment. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (99100) provided May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0651) and segmental 
pneumatic appliance (E0667) provided January 25, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you have attached 
the supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says the 
documentation submitted did not sufficiently support the billed supply code. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
appliance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do not support that the enrollee meets the 
Medicare criteria for the DME items.  
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 pneumatic compression device and appliance have not been met. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression device (E0651) and segmental 
pneumatic appliance (E0667) provided January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), office visit 
(99203), and the electrical stimulation (G0283) rendered by the out-of-network (OON) provider on  
February 15, 2022 and February 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an out-of-network provider. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98941), office visit (99203), and the 
electrical stimulation (G0283) rendered by the out-of-network (OON) provider on February 15, 2022 and 
February 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on April 7, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you were unaware that if you were treated 
by an ambulance and not transported that the services would not be covered. The Plan denied your request. The 
Plan says since there was no transport, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on April 7, 2022.