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

 
We decided that the Plan does not have to pay for the virtual psychotherapy visit (9084) provided on December 
22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the virtual visit. You say that you were under storm warning and the roads were 
horrible. You decided to do a phone visit to protect your own lives. You have been in therapy since 6 years old 
and only call for appointments when necessary for your health. The Plan denied your request. The Plan says 
enrollees must receive their virtual care services from an in-network provider. Virtual care is not covered out 
of 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 the virtual psychotherapy visit (9084) provided on 
December 22, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniGraf test (0118U) provided on May 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that please be advised the referring physician 
ordered specialized testing for this enrollee and forwarded the tests directly to you. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the OmniGraf test (0118U) provided on May 17, 
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 Dexcom G6 CGM sensor. 
 
You asked the Plan to pre-approve a CGM sensor. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related supplies 
have not been met. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G6 CGM sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 4, 2022. 
 
You asked the Plan to pay for the office visit. You say that you went to a new chiropractor, and you were taken 
back to discuss your condition with the doctor. You say she examined you but could not do any manipulation 
on your back without an x-ray to show what was wrong. The Plan denied your request. The Plan says only 
manual manipulation is covered 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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that your lab is not involved in direct patient care, so 
you are unable to get a referral for your services. 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 September 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on August 4, 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 order. 
 
The Plan must follow Medicare rules. The rules say that HHAs may not submit a claim until after all services 
are provided for the period and the physician has signed the plan of care and any subsequent verbal order. 
 
We looked at the file and Medicare rules. The file shows that there is no valid order for the date of service at 
issue. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
27, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was used during the 
patient's surgery. The Plan denied your request. The Plan says this device is not separately paid when used in a 
facility. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. You specified that this device was only used 
in a facility, not in the patient's home, so there is no separate payment available under Medicare rules. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on 
September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services provided on October 20, 
2022. 
 
You asked the Plan to pay for the medical services. You say that this was medically necessary and should be 
reimbursed. The Plan denied your request. The Plan says this was not billed with the proper POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code for services should be reported to 
match the location in which the TC was provided. 
 
We looked at the file and Medicare rules. In this case, the POS code used was for outpatient but the Plan 
provided evidence showing that the enrollee was inpatient on this date of service. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided 
that the Plan does not have to pay for the blood bank physician services provided on October 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) scan 
(73706). 
 
You asked the Plan to pre-approve a CTA. You say that the requested service is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CTA. Our reviewer says that the 
requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has non-specific right-thigh pain. No physical exam is provided in the records. No evaluation of pulses 
has been done. No venous or arterial ultrasound has been provided. 
 
 
  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 CTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a CTA scan (73706).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 14, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this item was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says this item is not covered outside of the 
home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. It is clear that this item was provided solely 
for use during surgery and not for use in the patient's home.  Medicare does not make separate payment in this scenario. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device 
provided on October 14, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of radiofrequency ablation. We decided that the Plan does 
not have to pre-approve 3 additional levels of radiofrequency ablation.  
 
You asked the Plan to pre-approve radiofrequency ablation services (64635, 64636) at 5 levels. You say that 
the requested services are a medical necessity for the enrollee. The Plan says that the request is not medically 
necessary. 
 
  We decided that the Plan has to pre-approve 2 levels of radiofrequency ablation.  
 
The Plan follows Medicare rules. Medicare rules say that an 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 radiofrequency ablation. Our reviewer 
says that 2 levels of radiofrequency ablation are medically reasonable and necessary in this case. Our physician 
reviewer found that utilization criteria limit the RFA to 2 levels bilaterally per session. Therefore, only 2 levels 
of RFA are deemed medically reasonable and 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 radiofrequency ablation have been met. Therefore, we decided that the Plan has 
to pre-approve 2 levels of radiofrequency ablation.  
 
We also decided that the Plan does not have to pre-approve 3 additional levels of radiofrequency 
ablation. 
 
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 3 additional levels of radiofrequency 
ablation. Our reviewer says that 3 additional levels of radiofrequency ablation are not medically reasonable and 
necessary in this case. Our physician reviewer found that utilization criteria limit the RFA to 2 levels bilaterally 
per session.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional levels of radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 3 additional levels of radiofrequency ablation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left ankle orthotic (L1971) provided on September 21, 
2022. 
 
You asked the Plan to pay for the orthotic. You say that you do not agree with this denial. The Plan denied your 
request. The Plan says the documentation does not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the records provided indicate pain in the enrollee's right foot. The orthotic provided to 
the enrollee was for the left ankle. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the left 
ankle orthotic (L1971) provided on September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 12, 2022, 
through June 15, 2022, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code A41.9-Sepsis, unspecified 
organism. 
 
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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the documentation does not support the secondary diagnosis of A41.9-
Sepsis. Our physician reviewer found the member presented with fever and altered mental status. The member 
had a reported temperature of 101.6. In the emergency department the temperature was at 99.1. The members 
heart rate was at 123, blood pressure 120/72, RR 16, and oxygen saturation at 96%. The member was oriented 
and was in no acute distress. Therefore, diagnosis code A41.9-Sepsis, unspecified organism is not the 
appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 12, 2022, through June 15, 2022, and billed with diagnosis 
code A41.9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this service is 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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on September 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 16, 2022, to June 
14, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the HHA notifies Medicare systems via 
submission of an NOA. 
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not correspond to an NOA filed for the first date in 2022 as required. Based on this information, we find 
that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the 
Plan does not have to pay for home health services provided from May 16, 2022, to June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service October 11, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99140 is considered bundled 
and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service October 11, 2022.
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) 
(87631) provided August 6, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the National Emergency Declaration has yet 
to have ended and, therefore, the extended timeframe for appeals submission remains in effect. The Plan denied 
your request. The Plan says the claim was received after the timely filing limitation. 
 
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 the laboratory service was not filed until November 22, 2022. 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 infectious agent detection by nucleic acid (DNA or RNA) 
(87631) provided August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing provided on October 17, 2022.  
You asked the Plan to pay for SelectMDx genetic testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says this test does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable 
and necessary and covered nationally when the criteria listed in the Medicare rules section of this letter have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met.  Specifically, we determined that SelectMDx genetic 
testing does not have FDA clearance. Therefore, we decided that the Plan does not have to pay for SelectMDx 
genetic testing provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee needs this device to monitor blood 
glucose level. The Plan denied your request. The Plan says criteria for coverage of a CGM are not met because 
the enrollee is not on insulin. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 14, 2022.