Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the counseling services you received from April 13, 2022, to 
May 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not part 
of the Medicare program. 
 
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. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the counseling services you received 
from April 13, 2022, to May 3, 2022.
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 June 26, 
2021. 
 
You asked the Plan to pay for procedure code 99100. 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 June 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home services (G0088, J7999, 62369) provided on 
September 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as the services on the 
claim did not match the services that were authorized. 
 
  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 home services (G0088, J7999, 62369) provided on 
September 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on May 11, 2022, and May 12, 2022, 
by an OON provider. 
 
You asked the Plan to pay for office visits. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 office visits provided on May 11, 2022, and May 
12, 2022, by OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ultrasound provided on April 9, 2022. 
 
You asked the Plan to waive the coinsurance for an ultrasound. You say that you should not be responsible to 
pay this. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance up to $75 per day for diagnostic radiology services.  
 
 
 
 
 
 
 
 You have been asked to pay $23.69 for an ultrasound. The provider billed $810; the Plan allowance was 
$118.45; $118.45 x 20% = $23.69. An ultrasound falls 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 coinsurance for an 
ultrasound provided on April 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 2, 2022. 
 
You asked the Plan to pay for outpatient hospital services. You say that this claim was billed correctly. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because test code 
80320 has a Status Indicator of B. 
 
The Plan must follow Medicare rules. Medicare rules say that code 80320 has a Status Indicator of B which 
causes the whole claim to be returned to the provider.  
 
We looked at the file and Medicare rules. You billed code 80320 on this claim, which is not recognized by 
Medicare for the outpatient prospective payment system. Therefore, the whole claim is returned to you for 
correction. Based on this information, we decided that Medicare rules for coverage of outpatient hospital 
services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital 
services provided on March 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay from December 15, 2021, to 
December 27, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you are unable to pay this. The Plan 
denied your request. The Plan says the cost share was applied correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment per day for days 1 to 20 and a $172 copayment per day for days 21 to 100.  
 
You have been asked to pay $1032 ($172/day x 6 days) for a SNF stay. You received SNF care for a total of 26 
days without having been discharged from SNF care for 60 consecutive days: November 19, 2021, to 
November 30, 2021 (12 days); December 1, 2021, to December 3, 2021 (2 days); December 12, 2021, to 
December 27, 2022 (12 days). A SNF stay falls within the Skilled Nursing Facility (SNF) 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 a skilled nursing facility (SNF) stay from 
December 15, 2021, to December 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ultrasounds provided April 28, 2022. 
 
You asked the Plan to waive the coinsurance for the ultrasounds. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for all for all other Medicare-covered diagnostic radiology services (not including x-rays).  
 
 
 
 
 
 
 You have been asked to pay $184.58 for ultrasounds. An ultrasound falls 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 coinsurance for 
the ultrasounds provided April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this equipment is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage for the requested CGM 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic testing provided on August 3, 2021. 
 You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this testing was ordered for screening purposes which is not covered by 
Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for cardiovascular 
genetic testing provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left stellate ganglion block (64510). 
 
You asked the Plan to pre-approve the injections. You say that you are appealing the denial of preauthorization 
for the left stellate ganglion block. The Plan denied your request. The Plan says the requested service is not 
reasonable and necessary 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a stellate ganglion block (also called a cervicothoracic sympathetic block) is used primarily to 
treat Complex Regional Pain Syndrome (CRPS), but has also been used to treat refractory angina, phantom 
limb pain and vascular insufficiency (such as Raynauds or frostbite), hyperhydrosis, and other conditions. The 
clinical effectiveness of a stellate ganglion block for the requested service can be defined as undetermined. The 
review has determined that the requested stellate ganglion block is 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left stellate ganglion block (64510).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional complimentary non-emergent transportation 
benefit. 
 
You asked the Plan to pre-approve additional complimentary non-emergent transportation benefit. You say that 
you are requesting additional transportation trips due to psychiatrist requirements. The Plan denied your 
request. The Plan says trips have exceeded the benefit limitation of 100. 
 
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 100 trips per year.   
We looked at your request, the records in the case file, and the rules. As of August 8, 2022, you have scheduled 
100 one-way trips. 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 complimentary non-emergent transportation benefit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visits provided on February 16, 2022. 
 
You asked the Plan to pay for the services provided. You say that reconsideration for medical necessity has 
been requested. The Plan denied your request. The Plan says the rules for reimbursement have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The claim information does not show that a condition code suitable for 
payment was billed. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient clinic 
visits provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker. 
 
You asked the Plan to pre-approve upright walker. You say that you have a compound fracture and a regular 
walker is detrimental to ambulation. The Plan denied your request. The Plan says the denial of authorization for 
this item is correct, because there is a lack of information to justify the need for this. 
 
The Plan follows Medicare rules. Medicare rules state that certain clinical criteria apply to the coverage of 
walkers and related accessories.  
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 upright walker. Our reviewer says that 
you do not meet the Medicare criteria for the requested upright walker. Our physician reviewer found your gait 
is described as antalgic but records do not otherwise document why an upright walker is required as opposed to 
a standard walker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upright walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an upright walker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight pharmacogenomics testing (81479) provided on 
April 1, 2022. 
 
You asked the Plan to pay for pharmacogenomics testing. You say that that these services were necessary and 
ordered by a physician. The Plan denied your request. The Plan says there is insufficient information provided 
to show that the criteria for coverage of this test are met. 
 
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 Medicare 
criteria are met. The rules say that tests which are not ordered by a physician who is treating the beneficiary are 
considered not medically reasonable and necessary. The rules also say that for pharmacogenomics (PGx) 
testing to be covered, a patients medical record must clearly reflect that the clinician has made an initial 
personalized decision for the patient based on the patients diagnosis, the patients other medical conditions, 
other medications the patient is taking, past medical history and other factors.  
 
We looked at the file and Medicare rules. Based on the information provided, we decided that there is 
insufficient information to verify that Medicare criteria for PGx testing have been met. Specifically, the only 
records provided include the test requisition form and results. There are no previous records to show that the 
ordering physician is treating the enrollee, and there is no evidence of the clinicians initial personalized choice 
in medications for this enrollee. There is also no record of which requested drugs are being considered for 
which indication(s), as there are multiple reported on the requisition form. Without additional information, it 
cannot be confirmed that coverage criteria are met in this case. Therefore, we decided that the Plan does not 
have to pay for GeneSight pharmacogenomics testing (81479) provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and wound debridement provided on February 
1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and wound debridement. You say that this was a medical 
necessity. The Plan denied your request. The Plan says the member has to use participating providers unless 
urgent or emergent. The Plan says that the services performed were neither. 
 
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 and wound debridement provided 
on February 1, 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 services (U0004) provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for code 
U0004 is bundled into payment for code U0003. 
 
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 U0004 
is a column II code to column I code U0003 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 services (U0004) provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this pathologist was the only one available. The 
Plan denied your request. The Plan says these services were provided OON without a referral or 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 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 lab services provided on January 27, 2022, 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 compression stockings identified with code A6533 that 
were issued on February 8, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you need these stockings daily. The 
Plan denied your request. The Plan says the items received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6533 that were issued on February 8, 2022.