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

 
We decided that the Plan does not have to pay for the Pigmented Lesion Assay (PLA) provided to the enrollee 
on September 7, 2021. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the testing cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the Pigmented Lesion Assay (PLA) is covered 
when the lesion is between 5mm and 19mm. 
 
The case file clearly shows that this testing was done for a 4mm lesion. Based on this information, we decided 
that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Pigmented Lesion Assay (PLA) provided to the enrollee on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement services (11721-Q8) provided on  
June 23, 2021. 
 
You asked the Plan to pay for code 11721-Q8. You say that you would like the plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says this claim is a duplicate to a previously paid claim. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the Plan's contract, and Medicare rules. The file shows that the provider billed duplicate 
claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of 
service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the 
Plan does not have to pay for the nail debridement services (11721-Q8) provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  
September 14, 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 denied codes remain not supported. 
 
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 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 laboratory services provided to the enrollee on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  
October 13, 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 claim does not follow industry standard coding rules. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
laboratory services provided to the enrollee on October 13, 2021.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs, used oxygen via nasal cannula and had routine foley catheter care. You were at a moderate assist to 
dependent level for functional mobility. You do not require skilled nursing or therapy services on a daily basis. 
You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility setting. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) screening testing 
provided to the enrollee on April 14, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says multiple codes should not be used to report this testing. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) screening testing provided to the enrollee on April 14, 2021.
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 the physician's services. The Plan denied your request. The Plan says You 
or your physician have not provided clinical information to indicate the services you are requesting cannot be 
provided by 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to 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: Transportation
Decision: Favorable

 
We decided that the Plan has to hold you harmless for ambulance services you received on March 17, 2021. 
 
You asked the Plan to hold you harmless for the ambulance services. You say that these services were 
medically necessary and should be covered regardless of the diagnoses billed on the claim. The Plan denied 
your request. The Plan says that the ambulance company billed these services incorrectly and is unwilling to 
submit a corrected claim. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The ambulance services in question were provided by a contracted provider. As a contracted provider, the 
ambulance company is supposed to know what services are covered and how to appropriately bill for those 
services.  The Plan is responsible for ensuring that their own contract providers bill correctly.  You should not 
be held responsible for a Plan contract provider's failure to bill appropriately.  Because these services were 
provided by a contract provider, under Medicare rules, this means the ambulance services are considered 
approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for ambulance services you 
received on March 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services coded as 82310, 82728, 83540 and 83550 
provided on September 15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that at this time, there is no contractual 
agreement in place which indicates that the CPT codes billed are included in the dialysis rate. It is your position 
that these CPT codes need to be reprocessed for payment due. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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. Also the Centers for Medicare and Medicaid Services (CMS) has an established policy for 
patients with ESRD indicating that the dialysis center is responsible for laboratory services related to the 
treatment of ESRD. 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 coded as 82310, 82728, 83540 
and 83550 provided on September 15, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a device check provided on September 20, 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 Original Medicare would be responsible for payment of this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee passed away and ended Medicare Hospice benefits on September 19, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay 
for a device check provided on September 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits (97110). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had prior therapy and the documentation does not reveal that 
you require the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. You are compliant in a home exercise program. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits (97110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient hospital clinic visit provided on December 22, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital clinic visit. You say that it was medically necessary to 
treat the enrollee and would like for the proper reimbursement for the service rendered. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network 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 an outpatient hospital clinic visit provided on 
December 22, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saxenda. 
 
You asked the Plan to pre-approve Saxenda. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Saxenda.  
 Benefits for Saxenda may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 29, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the appointment was a follow up 
visit, and it should be billed as such with no copayment. The Plan denied your request. The Plan says the 
proper copayment was applied for the service that was rendered. 
 
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 $5 
copayment for each Medicare-covered visit with a PCP.  
 
  You have been asked to pay a $5 copayment for the office visit. The office visit falls within 
Physician/Practitioner services, including doctors office visits 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 an office visit provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided 
September 13, 2021. 
 You asked the Plan to pay for the laboratory service. You say that this was ordered by the treating physician 
because the test results were needed to help determine the course of treatment for this enrollee. Please find 
supporting documentation and evidence to support medical necessity. The Plan denied your request. The Plan 
says Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making 
in the clinical 
management of the patient and will be denied automatically as not medically necessary and screening testing. 
 
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 test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for targeted genomic sequence analysis (81455) provided September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 14, 2020, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician was unaware they 
you were an out-of-network provider. The Plan denied your request. The Plan says the rendering and referring 
providers are both out-of-network providers and there was no 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 laboratory services provided on December 14, 
2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lens; tint, any color, solid, gradient or equal, 
excludes photochromatic, any lens material, per lens (V2745). 
 
You asked the Plan to pre-approve addition to lens; tint, any color, solid, gradient or equal, excludes 
photochromatic, any lens material, per lens (V2745). The Plan denied your request. The Plan says the Plan did 
not receive notes to support the need for tinted lenses. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 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 addition to lens; tint, any color, solid, 
gradient or equal, excludes photochromatic, any lens material, per lens (V2745) have been met. Therefore, we 
decided that the Plan does not have to pre-approve addition to lens; tint, any color, solid, gradient or equal, 
excludes photochromatic, any lens material, per lens (V2745).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the stress test provided on December 1, 
2021. 
 
You asked the Plan to waive the deductible for the stress test. You say that you want to be charged the lower 
copayment amount. The Plan denied your request. The Plan says the deductible amount charged is correct. 
 
 
 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 $200 
copayment after the deductible is met for each advanced imaging service (e.g., MRI, CT and PET scans, 
nuclear medicine, and stress tests).  
 
You have been asked to pay $528.99 towards your deductible for the stress test. Your deductible was not met 
prior to the stress test provided on December 1, 2021. A stress test 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 deductible 
for the stress test provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service November 
24, 2021. 
 
You asked the Plan to pay for procedure code 99153. You say that this service should be paid. The Plan denied 
your request. The Plan says this service was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 procedure code 99153. Our reviewer says that this code was 
not billed correctly and is not separately payable. Our reviewer found these services were billed with place of 
service 22 (On Campus-Outpatient Hospital). According to Medicare policy, denials will occur for code 99153 
when performed in a facility place of service (POS) setting. Medicare assigned this code a Professional/ 
Technical Component (PCTC) indicator "3" effective for dates of service on or after January 1, 2017, per 
Change Request 9780 (Change Request 9780). Technical components are not separately payable when 
performed by a physician in a facility setting because the facility has staff on hand to perform those services  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99153 billed for date of service November 24, 2021.