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

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network and authorization was not obtained prior to 
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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the enrollee was seen for right lower 
extremity ulcer and vaccinations. It would have been medically reasonable to delay the services until a later 
date when enrollee returned to their service area. 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 office visit have not been met.  
 
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 pay for the office visit. Therefore, we decided that the Plan does not 
have to pay for an office visit provided on January 4, 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 continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you do not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were 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 August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on August 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a telehealth visit. You say that you were not aware the provider was an out of 
network provider. The Plan denied your request. The Plan says there was no prior authorization obtained prior 
to the services provided. 
 
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 telehealth visit provided on August 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 pre-approve genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has right knee osteoarthritis. The enrollee has done physical therapy and 
continues with a home exercise program. The enrollees medication trials have included Celebrex, Diclofenac 
gel, Ibuprofen, Mobic, Gabapentin, Oxycodone and Xtampza. The enrollee has previously had 
viscosupplementation with Supartz and Synvisc. The enrollee previously had genicular nerve blocks without 
improvement. This request is considered an experimental/ investigational technique which is the subject of 
ongoing clinical trials. Therefore, the enrollee does not meet criteria for the requested services. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of loop monitor (33285). 
 
You asked the Plan to pre-approve the insertion of loop monitor. You say that the service is medically 
necessary. The Plan denied your request. The Plan says there is no record of syncope. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the insertion of loop monitor have not been met. Specifically, an ILR is used when syncope is 
thought to be cardiac related, the records submitted for this member do not indicate a history of syncope. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of loop monitor (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the telehealth services provided from February 5, 
2022, to March 28, 2022. 
 
You asked the Plan to reimburse you for the telehealth services. You say that the plan approved you to see this 
provider. You say that you needed someone to prescribe your medication. You also say that you should be 
reimbursed as you had to pay upfront. The Plan denied your request. The Plan says the claims denied correctly. 
 
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 telehealth services have been met. 
Specifically, the file does not include the amounts that were paid for the specific services in this case. Without this information, we cannot determine the cost share for these services. Therefore, we decided that the Plan 
does not have to reimburse you for the telehealth services provided from February 5, 2022, to March 28, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of any joint of the upper 
extremity (73221). 
 
You asked the Plan to pre-approve an MRI of any joint of the upper extremity. You say that an MRI is the only 
way to figure out if you have a rotator cuff tear that is still repairable, or if some form of shoulder replacement 
would be the only option The Plan denied your request. The Plan says that this request is denied because the 
medical records received do not indicate six weeks of provider directed treatment during the last twelve weeks, 
and no follow-up visit with the provider to document failure of conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of any joint of the upper 
extremity. Our reviewer says that an MRI of any joint of the upper extremity is reasonable and necessary for 
you. Our physician reviewer found all provocative maneuvers of the left shoulder are positive for rotator cuff 
tear including Hawkins and Neer tests. Our reviewer found that your x-rays showed degenerative changes of 
the glenohumeral joint. Our physician reviewer also found that the request to see if there is a rotator cuff tear 
that could be repaired arthroscopically versus a joint replacement can only be assessed with an MRI and thus 
the requested exam should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of any joint of the upper extremity have been met. Therefore, we 
decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of any joint of the upper 
extremity (73221).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) scan of the brain 
(70551) provided on August 2, 2022. 
 
You asked the Plan to pay for the MRI services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-
10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
In this case, this service was billed with a primary/first-listed diagnosis code of F01.50 (vascular dementia 
without behavioral disturbance). Certain conditions have both an underlying etiology and multiple body system 
manifestations due to the underlying etiology. For such conditions, it is required that the underlying condition 
be sequenced first followed by the manifestation. That means the primary/first-listed diagnosis code is incorrect 
for this service billed. Based on this information, we decided that Medicare rules for coverage of the MRI 
services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance imaging (MRI) scan of the brain (70551) provided on August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records show medical necessity. The 
Plan denied your request. The Plan says the service is included within the global surgery package. 
 
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 99205 was billed with code 31575. CPT code 31575 has a global surgery indicator of 
000. Evaluation and management services on the day of the endoscopic procedure are included in the payment 
for the procedure.  
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99205 billed for date of 
service June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH and with the current medical conditions may be adequately cared for. The Plan denied 
your request. The Plan says the enrollee's continued care needs include wound care and intravenous antibiotics. 
When ready to leave the hospital, the enrollee may safely receive this care in another setting, such as a Skilled 
Nursing Facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested LTACH services are not appropriate for the diagnosis and condition of 
the enrollee and will be able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) provided on November 
12, 2021. 
 
You asked the Plan to pay for detection test by nucleic acid for multiple types of respiratory virus, multiple 
types or subtypes, 12-25 targets. You say that this testing was COVID-19 related. The Plan denied your 
request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the requested testing is for greater than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets have not been met. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid 
(DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) 
provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for injection and hospital services provided on 
September 1, 2022. 
 
You asked the Plan to waive the cost share for injection and hospital services. You say that you are disputing 
the share cost. 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 $40 
copayment for Medicare Part B Prescription Drugs and $150 for Outpatient surgery and other medical services 
provided at hospital outpatient facilities and ambulatory surgical centers. 
 
You have been asked to pay $40 copayment for injection and $150 copayment for hospital services. This items/services fall within the Medicare Part B Prescription Drugs and Outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit categories. 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 cost share for injection and hospital services provided on September 1, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on November 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you want to appeal the services in this case. 
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, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on November 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 30, 2022, to 
August 28, 2022. 
 
You asked the Plan to pay for the home health services. You say that the NOA was filed timely. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked at the file and the Medicare rules. We find that the claim at issue does not have an admission date in 
2022 that matches the date on the NOA which as required. Based on this information, we find that the 
Medicare rules for payment have not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from July 30, 2022, to August 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 99284. The Plan denied your request. The Plan says payment for 
code 99284 is bundled into payment for code 99285. 
 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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service September 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service March 3, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that the codes do 
not require a modifier. The Plan denied your request. The Plan says the professional interpretation must be 
separately billed with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with the CPT codes. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service 
March 3, 2022.