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

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 25, 
2021. 
 
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 this requires modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
 
CPT 88360: 
 
Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), 
quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual 
 
CPT 88381: 
 
Microdissection (ie, sample preparation of microscopically identified target); manual 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the services were provided by a 
professional, and therefore an appropriate modifier would need to be appended for the services provided. 
 
We looked at this coder'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 August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 16, 
2021. 
 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 35701 is "Exploration not followed by surgical repair, 
artery; neck (eg, carotid, subclavian)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
include documentation of freeing an artery, such as the carotid artery or the subclavian artery, for examination, 
not followed by surgical repair. This code is not to be used to report exploring and identifying an artery when 
performed in conjunction with free flaps.  
We looked at this coder'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 surgical services provided to the enrollee on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for wound care services provided from 
January 25, 2022, to February 22, 2022. 
 
You asked the Plan to reduce the copayments for the wound care. You say that you were only informed of a 
$40 copayment at the times of service. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $250 
copayment for surgery services at an outpatient hospital. 
 
 
 
 
 
 Dates of Service Copayment per EOC Actual Amount Billed 
January 25, 2022 $250 $113.32 
January 28, 2022 $250 $146.63 
February 1, 2022 $250 $113.32 
February 8, 2022 $250 $146.63 
February 15, 2022 $250 $113.32 
February 22, 2022 $250 $146.63 
Total: $1,500 $779.85 
 
You have been asked to pay a total of $779.85, which is less than the $1,500 total copayments for the wound 
care. The wound care falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers 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 reduce the copayments 
for wound care services provided from January 25, 2022, to February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on October 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 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 (G0483) provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with a cardiologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to see the requested provider 
because he is a highly recommended cardiologist. The Plan denied your request. The Plan says your records do 
not indicate that you have an emergent or urgent medical condition or are in need of specialized service(s) that 
are not available in the network. There are in-network provider(s) within a reasonable distance from your 
location that can provide this service or item. 
 
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 
an office visit (99204) with a cardiologist to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on May 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on May 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided March 8, 2022. 
 
You asked the Plan to pay for the orthosis. You say that Medicare would have paid this DME claim due to the 
enrollee's PCP prescribed the DME within 6 months from a face-to-face visit, the packing slip was provided a well as the proof of delivery. The Plan denied your request. The Plan says the records do not support the billed 
service. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provider's record stated that he saw the enrollee for low back pain on March 1, 2022. In the 
notes of the March 1, 2022 encounter there is no mention by the provider that he determined a lumbar brace 
would be a reasonable and necessary treatment for the condition. The Medical record dated March 1, 2022 does 
not state the provider prescribed, or considered, a lumbar brace for this enrollee. The review has determined 
that the medical records provided do not meet the 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultralightweight wheelchair (K0005) and related supplies 
provided on February 23, 2022. 
 
You asked the Plan to pay for an ultralightweight wheelchair. You say that the ultralightweight wheelchair at 
issue was a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment for 
durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that an ultralightweight wheelchair was used in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pay for an ultralightweight wheelchair (K0005) and related supplies provided on 
February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a total hip arthroplasty and physical 
therapy (PT) services performed by an out-of-network (OON) provider on January 13, 2022. 
 
You asked the Plan to waive the coinsurance for the hip arthroplasty and PT services. You say that you were 
informed that the provider was in-network. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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% 
coinsurance for surgery services at an out-of-network (OON) facility. 
 
 Your contract with the Plan also clearly says that you must pay a 50% coinsurance for physical therapy 
services at an out-of-network (OON) facility. 
 
Service Allowed Amount 50% Coinsurance (OON) 
Hip Arthroplasty $11,643.50 $5,821.75 
Physical Therapy $95.27 $47.63 
Total:  $5,869.38 
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$5,869.38, which is 50% of the allowed amount for the hip arthroplasty and PT services. The hip arthroplasty 
falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. The physical therapy falls within the Outpatient Rehabilitation 
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 coinsurance for a total hip arthroplasty 
and physical therapy (PT) services performed by an out-of-network (OON) provider on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 14, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware of the enrollee changing his 
insurance plan. The Plan denied your request. The Plan says prior authorization was not obtained for out-of-
network care prior to the enrollee's 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 the office visit provided on January 14, 2022, by 
an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiac device evaluation (93293) provided on October 6, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cardiac device evaluation. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and 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 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 cardiac device evaluation (93293) provided on 
October 6, 2021, 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 4, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the provider is 
not under contract with the health Plan and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided January 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is 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 88305 is not supported in the medical record. Specifically, this service has a 
professional component / technical component indicator of 1. This code was billed by another provider for the 
same date of service at place of service 22, outpatient hospital. 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 (88305) provided January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digitally programmable analog, binaural 
(V5250) provided December 17, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were never informed of the rules the Plan is 
applying to your claim. The Plan denied your request. The Plan says the hearing aids are not covered because 
they were purchased on the internet. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan does not 
cover internet purchased hearing aids. 
 
We looked at the file and the Plan's rules. In this case your purchased hearing aids on the internet. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aid, digitally programmable analog, binaural (V5250) 
provided December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 tests (U0002) provided on January 15, 2022. 
 
You asked the Plan to pay for COVID-19 tests. You say that the item at issue was a medical necessity for you. 
The Plan denied your request. The Plan says the item at issue is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and COVID-19 
tests is an OTC item. Therefore, we decided that the Plan does not have to pay for COVID-19 tests (U0002) 
provided on January 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is 
correct, because the enrollee is not in imminent danger. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient psychiatric care. Our physician reviewer 
found it is not expected that the enrollee would improve in a reasonable period of time as the enrollee does not 
have dangerousness to self or others, auditory or visual hallucinations, delusions, or behavioral issues. It does 
not appear medically reasonable and necessary to have care provided at the acute inpatient level of care rather 
than 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require 
transportation for dialysis treatments. The Plan denied your request. The Plan says that you have exhausted this 
benefit. 
 
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. The Plan covers a maximum of thirty-two (32) trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the omental flap (49905) provided on February 10, 2022. 
 
You asked the Plan to pay for the omental flap (49905). You say that the operative report proves the omental 
flap was created and completed. You say that CPT code 49905 is payable and should be processed. The Plan 
denied your request. The Plan says procedure code 49905 is not supported by the medical records submitted. 
 
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 49905 is omental flap, intra-abdominal (List separately in 
addition to code for primary procedure). 
 
 
  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 the omental flap (49905). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not include enough documentation to verify an intra-abdominal omental flap was 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the omental flap (49905) have not been met. Therefore, we decided that the 
Plan does not have to pay for the omental flap (49905) provided on February 10, 2022.