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

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 24, 
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (E0486). 
 
You asked the Plan to pre-approve an oral device/appliance. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says that the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 oral device/appliance. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's RDI was greater than 30 and was not able to tolerate a PAP device. The 
oral appliance was ordered by a treating practitioner and provided by a dentist. The documentation meets the 
criteria for coverage for an oral appliance for sleep apnea. 
 
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 oral device/appliance have been met. Therefore, we decided that the Plan has 
to pre-approve an oral device/appliance used to reduce upper airway collapsibility, adjustable or non-
adjustable, custom fabricated, includes fitting and adjustment (E0486).  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 10, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim due to medically necessity for services rendered. The Plan denied your request. The Plan says the 
provider is out-of-network and it was determined these services can be received in-network. 
 
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 provided on March 10, 2022 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 18, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were 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 laboratory services provided on January 18, 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 an office visit received on October 7, 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 provider does not participate with the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit received on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on May 3, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on medical necessity. The Plan denied your request. The Plan says the claim has denied per Medicare 
guidelines. 
 
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 genetic testing services provided 
on May 3, 2021, have been met. In this case, very little documentation was received from the enrollees 
provider to indicate the medical necessity of the ordered testing. Without this documentation, the medical 
necessity and reasonableness of the provided testing cannot be ascertained. Therefore, we decided that the Plan 
does not have to pay for the genetic testing services provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81401, 81403, 81404, 81405, 
81406) provided on October 20, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that these services were medically and 
should be reprocessed for payment. The Plan denied your request. The Plan says the claim has not been billed 
in accordance with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81401, 81403, 81404, 81405, 81406) provided on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide In Vitro testing strips. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. 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 Accu-Chek Guide In Vitro testing strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88361, 88312, 88305 and 88104) 
provided on May 18, 2021. 
 
You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says Medicare rules for payment of this claim 
have not been met. 
 
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 looked at the file and Medicare rules. The records indicate that the enrollee was inpatient on the billed date 
of service and these services have been billed without a professional component modifier. Without this 
modifier, payment for these services is included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been 
met. Therefore, we decided that the Plan does not have to pay for the pathology services (88361, 88312, 88305 
and 88104) provided on May 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on May 11, 2020. 
 
You asked the Plan to pay for the therapeutic exercises. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says there is a more appropriate code to 
bill for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physical therapist must supervise PTAs. The 
services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) 
service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. In this case, a NPP has billed for the services of a PTA. This is not 
appropriate billing standards as the NPP does not meet the qualifications of a therapist based on Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) 
provided on May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve a rhythm monitor. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 a rhythm monitor. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had no history of atrial fibrillation, nor were any significant cardiac 
arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) 
was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke 
but without a known prior history of atrial fibrillation. Insertion of an ILR would not be considered medically 
appropriate and necessary in this patients clinical management. 
 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 rhythm monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including programming (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 17, 
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 August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this procedure is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 55-year-old woman with sacroiliitis. The requested procedure in this 
case is considered an experimental/investigational procedure because of the wide variation in efficacy reported 
in the peer reviewed literature. Therefore, the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the 
sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on October 6, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that the provider is out-of-network and it was 
determined these services were not urgent or emergent and prior authorization. The Plan denied your request. 
The Plan says the provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 Domiciliary services provided on October 6, 2021 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on October 25, 
2021. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says there is a more appropriate code to 
bill for the services rendered. 
 The Plan must follow Medicare rules. Medicare rules say that there must be direct supervision when an NPP is 
billing for the services provided incident to.  
 
We looked at the file and Medicare rules. In this case, there is no documentation that the billing nurse 
practitioner directly supervised the therapeutic activities performed by the physical therapist and the 
occupational therapist. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the 
therapeutic activities (97530) provided on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
13, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you were not told the 
laboratory was not in-network and you were not aware of any charges. The Plan denied your request. The Plan 
says coinsurance 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 $20 
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds.  
 
You have been asked to pay $8.46, which is less than the standard $20 copayment for laboratory services. 
Laboratory services fall 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 laboratory services provided on 
December 13, 2021.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided from January 3, 2022, 
through January 31, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you believed these services were 
covered by the health Plan. The Plan denied your request. The Plan says that charges for members electing 
hospice are considered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided us with proof of Hospice enrollment. Therefore, we 
decided that the Plan has to pay for subsequent nursing facility care provided from January 3, 2022, through 
January 31, 2022.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve protein supplements. 
 
You asked the Plan to pre-approve the supplements. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered for people with kidney disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve protein supplements.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 3, 
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 Current Procedural Terminology (CPT) code 33020-59 (1 Unit) remains not supported. 
 
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 code 33020 is "Pericardiotomy for removal of clot or foreign 
body (primary procedure)." 
 
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 the procedure report does not support 
removal of clot or foreign body as a separate procedure from CPT 33025, and therefore modifier -59 is not 
supported.  
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 surgical services provided to the enrollee on September 3, 2021.