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

 
We decided that the Plan does not have to pay for procedure codes 99214 and S9088 billed for date of service 
March 7, 2022.  
You asked the Plan to pay for procedure code 99214. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99214 
is a column II code to column I code 94640. 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. Code S9088 has a 
status of "I" and is not valid for Medicare payment. Therefore, we decided that the Plan does not have to pay 
for procedure codes 99214 and S9088 billed for date of service March 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopic partial colectomy, associated procedure 
and hospital inpatient admission to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve laparoscopic partial colectomy, associated procedure and hospital inpatient 
admission to be provided by an OON provider. You say that the services are necessary. The Plan denied your 
request. The Plan says there are in-network providers that are able to provide these services. Therefore, 
coverage criteria 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 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 laparoscopic partial colectomy, associated procedure and hospital inpatient admission to be provided by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
December 21, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the continuous glucose monitor (CGM) supplies rendered on 
December 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from December 25, 2021, to December 26, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were unaware of any 
copayments for these services. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency room visits.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided from December 25, 2021, to December 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found certainly using ultrasound on a daily basis is not unreasonable, but to bill for daily simple 
simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines. Billing for daily simulations or IGRT would not be furnished in 
accordance with accepted standards of medical practice 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image-guided radiation therapy (IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six outpatient visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve six outpatient visits. You say that you have been seeing this provider for 
seven years. The Plan denied your request. The Plan says the services have been requested out-of-network and 
there are in-network providers available. 
 
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 
six outpatient visits to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from July 12, 2021, to 
July 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that there was a lot of miscommunications as to what 
was covered and what was not covered. The Plan denied your request. The Plan says you have exceeded the 
number of visits that were approved. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided from July 12, 
2021, to July 21, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided from March 3, 2022, to 
March 5, 2022. 
 
You asked the Plan to pay for a self-administered drug. The Plan denied your request. The Plan says self-
administered medications are not covered. 
 
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 pay for a self-administered drug 
provided from March 3, 2022, to March 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on April 13, 2022. 
 
You asked the Plan to pay for an evaluation and prophylaxis. You say that these services should be covered. 
The Plan denied your request. The Plan says your annual dental maximum amount has been exhausted. 
 
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 have a $500 
annual dental maximum. 
 The record shows your annual dental maximum has been exhausted. You have been asked to pay $159 for an 
evaluation and prophylaxis. An evaluation and prophylaxis fall within the Dental Services 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 pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on 
April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 6, 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. 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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. The definition of code 87500 is infectious agent 
detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), 
amplified probe technique. The definition of code 87505 is infectious agent detection by nucleic acid (DNA or 
RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 3-5 targets. The definition of code 87641 is infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that CPT codes 87491, 87500, 87505, 87641, and 87798 are not supported in the medical record. 
Specifically, there is no documentation of a laboratory report or results for these tests. Based on this 
information, we decided that Medicare rules for coverage of these services 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. In this case, we have confirmed that code 87493 
is a column II code to column I code 87505 and code 87640 is a column II code to column I code 87641. This 
claim has not been billed with an appropriate modifier to bypass the edit. The -59 modifier is not supported as a 
separate and distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been 
met. 
 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 6, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit provided on November 7, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says as 
a Medicare secondary payer, a benefit is payable when the primary insurance payers calculated amount is less 
than the Medicare allowed rate for the service. The primary payer paid in full the Medicare allowable benefit 
leaving a zero balance Medicare secondary benefit due. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. The file shows that the primary payer 
paid in full the Medicare allowable benefit leaving a zero balance for the Medicare secondary benefit due. 
Therefore, we decided that the Plan does not have to pay for emergency department visit provided on 
November 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (Q0092, R0075, 71045) provided 
February 4, 2022. 
 
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be billed as paid. 
 
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 Q0092, R0075, & 71045 is not supported in the medical record. Specifically, this 
service has a professional component / technical component indicator of 1 and was billed for place of service 
31, skilled nursing facility. The professional interpretation of the diagnostic test was not separately billed by 
the physician. Based on this information, we decided that Medicare rules for coverage of the portable x-ray 
services have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray services 
(Q0092, R0075, 71045) provided February 4, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to approve coverage for continued skilled nursing facility (SNF) services after 
August 8, 2022. 
 
You asked the Plan to approve coverage for SNF care. You say that you feel that continued SNF care is 
needed. The Plan denied your request. The Plan says that this was correctly denied beyond August 8, 2022, 
because your functional status plateaued, and you were discharged to long-term care. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before August 8, 2022. A copy of the signed NOMNC was requested; however, the Plan indicated 
that one was not required since you were discharged to the hospital. There is no evidence showing when this 
discharge occurred. Per the file, you were still at the facility on the date that the Plan is saying coverage ceased. 
 
The Plan must approve the SNF services until the date of discharge to the hospital. Therefore, we decided that 
the Plan has to approve coverage for continued skilled nursing facility (SNF) services after August 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pain management injection (62323) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says the services have 
been requested out-of-network and there are in-network providers available. 
 
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 
a pain management injection (62323) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that the in-network providers listed are not able 
to perform the type of hip surgery you need. The Plan denied your request. The Plan says the services have 
been requested out-of-network and there are in-network providers available. 
 
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 
an outpatient visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the hospital outpatient clinic visit for an 
assessment and management provided on December 29, 2021. 
 
You asked the Plan to waive the cost share for the outpatient clinic visit. You say that this was just a follow up 
visit, and you should not be charged this copay. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 there is a $425 deductible which applies to Outpatient Hospital Services. At the 
time this claim was processed, $0 of the $425 deductible had been met. The allowed amount of this claim is 
$48.53, resulting in a deductible amount of $48.53. 
 
The item or service you asked the Plan to waive falls within the benefit category Outpatient Hospital Services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $425 deductible which 
applies to Outpatient Hospital Services. This cost sharing is a contractual obligation that had not been met at 
the time the outpatient clinic visit was received on December 29, 2021. Therefore, we decided that the Plan 
does not have to waive the cost share for the hospital outpatient clinic visit for an assessment and management 
provided on December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services rendered on September 14, 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 Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the pathology services 
rendered on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on January 
19, 2022.