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

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service February 16, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that you disagree 
with the denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, 88360, and 88381 have a Professional/Technical indicator of 1. This 
means that CPT codes 88341, 88342, 88360, and 88381 have both a professional and technical component. In 
this case, CPT codes 88341, 88342, 88360, and 88381 have not been billed with an appropriate modifier to 
indicate the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for date of service February 16, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49505 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 49505. You say that the claim was submitted properly but 
continues to be denied. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 49505 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 49505 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 49505 billed for date of service March 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77385) provided on November 11, 2021 
to November 30, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 77385 is not supported in the medical record. Specifically, the records provided only 
cover some of the dates of service. Medical records were not submitted for all of the dates of service billed. 
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Therefore, we decided that the Plan does not have to pay for radiology services (77385) provided on 
November 11, 2021 to November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 4, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this service was medically necessary and 
reasonable. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the 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, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ostomy pouch, closed, with barrier attached, with built-in 
convexity, with filter (1 piece), each (A4417) provided May 27, 2022. 
 
You asked the Plan to pay for the ostomy pouch. You say that as per the enrollee's Primary insurance 
DMEPOS supplies are not covered under the enrollee's benefit plan. Please reprocess the claim as Medicare 
secondary payer. The Plan denied your request. The Plan says missing/incomplete/invalid prior insurance 
carrier's EOB. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
payer that is primary. The records provided include the primary payer's EOB which indicates the total billed 
amount is $300 and the allowed amount is also $300 but no payment was made due to invalid place of service. 
The primary payer billing is not complete. As the secondary insurer, the Plan cannot be held responsible for 
Ostomy pouch until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 
piece), each (A4417) provided May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from going to an IRF so that they 
can provide you aggressive therapy as well as proper pain control. The Plan denied your request. The Plan says 
IRF admission is not medically necessary as the patient can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for back and leg pain and your medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-
of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that this physician is the specialist that the emergency room doctor referred you to see. The 
Plan denied your request. The Plan says the services are available with an in-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 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 services at issue in this appeal. We found no exception that would require the 
Plan pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's 
services to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88341, 88342, 88360) provided on 
February 12, 2022. 
 
You asked the Plan to pay for pathology services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was billed as an inpatient service without a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical 
component (TC) of a physician pathology service provided to an inpatient or outpatient. 
 
We looked at the file and Medicare rules. The record indicates the pathology services at issue were provided to 
a hospital inpatient, but these services were not billed with a modifier indicating only the professional 
component, not the technical component, is being billed. Based on this information, we decided that Medicare 
rules for coverage of pathology services have not been met. Therefore, we decided that the Plan does not have 
to pay for pathology services (88341, 88342, 88360) provided on February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plan's network) will not be covered. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility for payment. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urology visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a urology visit. You say that you need this to be covered. The Plan denied 
your request. The Plan says there are other providers within your network who are close enough for you to go 
to. This is not an emergency visit; therefore, this is upheld. 
 
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 
a urology visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 10, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and reasonable. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology visit provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a dermatology visit. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 dermatology visit provided on June 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility regarding payment. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 5, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrical stimulator (A4595) provided on December 19, 
2021. 
 
You asked the Plan to pay for the electrical stimulator. You say that this equipment was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the electrical stimulator have been met. 
No medical records were submitted by the provider to support the services billed. Therefore, we decided that 
the Plan does not have to pay for an electrical stimulator (A4595) provided on December 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says if the enrollee needs medical care that Medicare require our plan to cover 
and the provider in our network cannot provider this care, the enrollee can get this care from an out-of-network 
provider. If this happens, the enrollees primary care provider (PCP) will refer the enrollee to the out-of-network 
provider. Be sure to get a referral (approval in advance) from their PCP before the enrollee uses 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 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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says SNF admission is not medically necessary as the patient does not need 
skilled nursing or skilled therapy on a daily basis. The patient's needs can be provided at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient does not have documented skilled nursing needs or documented skilled 
therapy needs.  Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the patients condition.  The patients care needs, custodial and intermittent, can, as a practical 
matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.