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

 
We decided that the Plan does not have to pay for lab services provided on September 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency anesthesia (99140) provided on September 
23, 2020. 
 
You asked the Plan to pay for the emergency anesthesia. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 99140 has a status indicator of B. 
 
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 99140 is not supported in the record. Specifically, CPT code 99140 has a status 
indicator of B. This means that the payment for CPT code 99140 is always bundled into the payment for 
another service or procedure.  
  
Based on this information, we decided that Medicare rules for coverage of the emergency anesthesia have not 
been met. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia (99140) 
provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on August 9, 2021. 
 
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted 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.  
 
We looked at the file and Medicare rules. The testing at issue was submitted with code 81455 and is not 
considered medically necessary. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne testing (81455) provided on August 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the original 
decision to not approve skilled nursing facility admission will be maintained. 
 
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 SNF services have been met. 
Specifically, medical records, the appeal request and the Plans original determination were not received. 
Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
May 26, 2021, to May 28, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
submitted documentation supports observation care. 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee is a 71-year-old male who presented to the emergency department 
with asymptomatic new-onset atrial fibrillation. On admission, his heart rate was controlled in the normal range 
and additional workup was negative for acute coronary syndrome or other condition. He was admitted for 
possible cardioversion but was stable and could have been completed at a lower level of care. There was no 
suggestion in the documentation that the enrollee would require hospital services that would likely cross 2 
midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 26, 2021, to May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on August 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99213 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 
 The provider submitted a claim for procedure codes 99213 and 99214. Code 99213 is a column II code with a 
modifier indicator of 1 when billed with column I code 99214. Code 99213 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the office 
visit rendered on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract eye surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that a network deficiency does not exist. 
 
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 
cataract eye surgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman procedure (Left Atrial Appendage 
Closure) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee will benefit from this procedure. 
The Plan denied your request. The Plan says that the records do not show that the enrollee is unable to take 
blood thinners on an ongoing basis. 
 
The Plan must follow Medicare rules. Medicare rules say that LAAC may be covered if the Medicare criteria 
have been met. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. This patient has an 
elevated risk of thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC score. There is no 
apparent contraindication to anticoagulation. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Watchman procedure (Left Atrial Appendage Closure) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection. 
  You asked the Plan to pre-approve the epidural steroid injection. The Plan denied your request. The Plan says 
the clinical information does not describe the type of pain covered for the requested procedure. 
 
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 the epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the CT of the cervical spine indicates appropriate alignment, no 
evidence of subluxation, no osseous narrowing of the spinal cord and degenerative spondylosis most 
prominently at the C5-C6 level. The MRA of the neck indicated no significant carotid or vertebral stenosis. 
There is no radiological pathology or physical exam findings suggestive of C6-C7 pathology. In addition, the 
clinical information provided does not show that the enrollee is participating in an active rehabilitation 
program, home exercise program, or functional restoration program. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone Cypionate for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Testosterone Cypionate for 
the enrollee.  
 Benefits for this drug 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 pay for the ultrasound and electric stimulation services provided on 
October 6, 2021. 
 
You asked the Plan to pay for the services provided. You say that you are requesting reimbursement. The Plan 
denied your request. The Plan says the services are not covered when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the file and the rules. The services at issue are not a covered benefit when provided by a 
chiropractor. Therefore, we decided that the Plan does not have to pay for the ultrasound and electric 
stimulation services provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
therapy rendered on September 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that TENS therapy for chronic low back pain (CLBP) is 
covered when the beneficiary is enrolled in an approved clinical study meeting specific requirements. 
 
We looked at the file and Medicare rules. The file shows that the services were not rendered to treat CLBP. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation 
(TENS) therapy rendered on September 7, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for magnetic resonance imaging (MRI) provided by an 
in-network outpatient hospital on November 8, 2021 
 
You asked the Plan to waive the coinsurance for MRI. You say that this charge should be covered by the plan. 
The Plan denied your request. The Plan says that the coinsurance amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for advanced imaging services provided at 
an in-network outpatient hospital facility.  
 
The Plan says you must pay $66.94, which is 20% coinsurance, for MRI. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for MRI. Therefore, we decided that the Plan has to 
waive the coinsurance for magnetic resonance imaging (MRI) provided by an in-network outpatient hospital on 
November 8, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on November 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 76770 (abdominal ultrasound) and 93976 (vascular study). 
Code 76770 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 
76770 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the abdominal ultrasound rendered on November 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services rendered by the out-of-
network (OON) provider from October 9, 2021, through October 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the outpatient therapy services rendered by the out-of-network (OON) provider 
from October 9, 2021, through October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) and influenza vaccination (90688, 
G0008) provided on October 19, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for an office visit and influenza vaccination. You say that the services at issue were 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-
network care have not been met. 
 
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 office visit (99213) and influenza vaccination 
(90688, G0008) provided on October 19, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on November 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). 
Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 
76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the abdominal ultrasound rendered on November 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on March 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until November 24, 2021. A valid Waiver of 
Liability (WOL) was not received until December 14, 2021. This means that more than one calendar year from 
the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to 
pay for the testing services rendered on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided on November 
24, 2021. 
 
You asked the Plan to pay for acupuncture services. You say that this is a covered service. The Plan denied 
your request. The Plan says this was not provided by an eligible practitioner. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules also say that acupuncturists frequently attempt to enroll in 
Medicare but are not eligible to do so. 
 
Review of the file and Medicare records indicates that the provider at issue is an acupuncturist and is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for acupuncture 
services (97810, 97811) provided on November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous vertebral augmentation (22514) rendered 
by the out-of-network (OON) provider on June 25, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the percutaneous vertebral augmentation (22514) rendered by the out-of-network 
(OON) provider on June 25, 2021.