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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 23, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on June 
13, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that the hospital was 
understaffed and did nothing for you therefore, you should not be responsible for the copayment. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency care 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 copayment for emergency room services 
provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (procedure codes 70450, 70551, 72141) 
provided to the enrollee on March 28, 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 the denied codes is: 
 
CPT 70450: 
 
Computed tomography, head or brain; without contrast material 
 
CPT 70551: 
 
Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material  
CPT 72141: 
 
Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material 
 
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 it appears that there may be some 
confusion on dates of the exams, as the signed reports are dated 3/27/21, and not 3/28/21. The services cannot 
be verified to have taken place on the billed date of service. There is a report of a computed tomography (CT) 
of the brain on 3/27/21 having been compared to a CT of brain of 3/26/21, of which no report was included. 
There was no CT of brain done on 3/28/21. In terms of the two magnetic resonance imaging (MRI) services, 
there is a report for these imaging services for 3/27/21, interpreted by the doctor. 
 
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 imaging services (procedure codes 70450, 70551, 72141) provided to the enrollee on March 28, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on May 29, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that the supplies should be covered. The Plan denied 
your request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery in this case. The date of service does not match the date 
on the packing or delivery slip. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) supplies (K0553), provided on May 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary and should be 
paid. 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 June 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper 
or lower extremity arteries (93922) provided on July 1, 2022. 
 
You asked the Plan to pay for the limited bilateral noninvasive physiologic studies. The Plan denied your 
request. The Plan says this service is not authorized because code 93922 is not a Medicare benefit for the 
diagnoses listed on the claim. 
 
The Plan follows Medicare rules. Medicare rules say that noninvasive physiologic studies of the upper or lower 
extremity arteries will be considered medically necessary if significant signs and/or symptoms indicate a high 
likelihood of limb ischemia, and the patient is a candidate for invasive therapeutic procedures. 
 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 limited bilateral noninvasive physiologic 
studies. Our reviewer says that the noninvasive physiologic studies of the lower extremity arteries provided on 
July 1, 2022, are not medically reasonable or necessary. Our physician reviewer found it does not appear that 
the enrollee has significant signs and or symptoms that indicate a high likelihood of limb ischemia. Our 
reviewer found that there are no complaints in the medical documentation of lower extremity rest pain and/or 
intermittent claudication. Our physician reviewer also found that the noninvasive physiologic studies of the 
lower extremity arteries were not medically reasonable or necessary in that the enrollee does not meet the 
Medicare criteria. 
 
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 limited bilateral noninvasive physiologic studies have not been met. 
Therefore, we decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries (93922) provided on July 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 30, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not go to the emergency department because the pain subsided, and you decided to wait until the next morning 
to contact your cardiologist and primary care physician. The Plan denied your request. The Plan says you 
refused ambulance transport, and this service is not covered by Medicare. 
 
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 March 30, 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 with no 
transport (A0998) provided on March 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99349) provided on August 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service was rendered by an OON provider, and there is no 
documentation that you were referred by a contracted provider. The Plan also says that you do not have OON 
benefits, 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 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 home visit (99349) provided on August 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 23, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on June 6, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment. 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 medication assisted treatment provided on June 6, 
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 a pre-operative appointment provided on provided on June 
15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pre-operative appointment. You say that the beneficiary did not have a choice 
of where she went for this service, please do not penalize the provider. 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 pre-operative appointment provided on provided 
on June 15, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry testing provided on May 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry testing. You say that the procedure was performed to hasten definitive 
diagnosis and to effectively treat the patients condition. 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 podiatry testing provided on May 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement standard wheelchair. 
 
You asked the Plan to pre-approve a replacement standard wheelchair. You say that your current standard 
wheelchair received in 2020 is too large for some areas in your home and you would like to exchange the chair 
for a smaller wheelchair. The Plan denied your request. The Plan says the rules for coverage have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for repairs to equipment 
up to the cost of replacement. Replacement may only be covered during the 5-year useful life when there is a 
specific incident which damages the item beyond repair. Replacement from wear from day-to-day activities is 
not covered within the 5-year lifetime. 
 
In this case, the current standard wheelchair has not been examined or evaluated to support that it does not fit 
you or your home properly and that it is not functional for you. The file shows that your living arrangements 
have not been changed since receiving the current standard wheelchair in 2020. Replacement cannot be 
provided without objective evidence that the standard wheelchair is damaged or not working. Based on the lack 
of any actual documentation of damage, replacement cannot be considered necessary at this time. Therefore, 
we decided that the Plan does not have to pre-approve a replacement standard wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service April 21, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that you would like this claim reprocessed and 
approved for payment. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on July 13, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that previously in 2021, a comprehensive eye exam 
included refraction. The Plan denied your request. The Plan says this service is not a benefit offered for every 
plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers this service when the refraction billed as part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the enrollee did not receive a 
routine eye exam, but received a medical eye exam. Based on this information, we decided that the Plan's rules 
for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye refraction (92015) provided on July 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sacral Nerve Stimulation. 
 
You asked the Plan to pre-approve a Sacral Nerve Stimulation. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary 
 
The Plan follows Medicare rules. Medicare rules say that the patient must have had a successful test 
stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured 
through voiding diaries.  
 
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 a Sacral Nerve Stimulation. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the records do not 
show a 50% or greater improvement in symptoms throughout the test stimulation period as required by the 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Sacral Nerve Stimulation have not been met. Specifically, the enrollee did not 
have greater than 50% improvement through test stimulation. Therefore, we decided that the Plan does not 
have to pre-approve a Sacral Nerve Stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 26, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 laboratory services provided on April 26, 2022, by 
an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on May 24, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $100 
copayment per day for a Medicare-covered ultrasound. Covered services include, but are not limited to 
diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan. 
 
You have been asked to pay a $100 copayment for ultrasound. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 
copayment for ultrasound on May 24, 2022.