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

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on December 21, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that these services were referred by your doctor. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and the ordering physician was also out-of-network with the Plan. 
 
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 ultrasound provided on December 21, 2021 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 pneumatic compression device and accessories to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that it is 
necessary for this equipment to be provided by an OON provider. The Plan denied your request. The Plan says 
there are in-network providers available to provide this device if medically necessary. 
 
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 pneumatic compression device and accessories to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has no skilled nursing needs. 
While the enrollee is receiving daily tube feeds, this now appears to be a long-term care issue. He is at his 
baseline level of function and does not require daily skilled therapy. As a practical matter, the enrollee does not 
require the necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. The file shows that procedure code 85060 was billed with POS code 
22 for outpatient hospital. This code has a PC/TC indicator of 8 and is not payable in this setting. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on December 9, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81227, 81355, 81400, 81401, and 81479) 
provided on December 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services (81227, 81355, 81400, 81401, and 81479) provided on December 22, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120), cleaning (D1110) and 
bitewing x-rays (D0274) provided on January 25, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you are an established patient with this dental 
provider, and you would like to keep seeing them. The Plan denied your request. The Plan says the provider in 
this case is not part of the Plan's network. You are responsible for 100% of the cost of dental care received out-
of-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Your contract with the Plan 
clearly states that you are responsible for 100% of the cost of out-of-network services. 
We looked at the file and the Plan's rules. The provider in this case is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, 
we decided that the Plan does not have to pay for the periodic oral exam (D0120), cleaning (D1110) and 
bitewing x-rays (D0274) provided on January 25, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies provided on September 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical supplies. You say that it was medically necessary to provide the 
medical supplies to the enrollee and would like the claim to be paid. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was 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 the medical supplies provided on September 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on January 
13, 2021, to April 6, 2021. 
 
You asked the Plan to pay for dental services. You say that you were never told that the dentist you used had 
opted out of Medicare. The Plan denied your request. The Plan says the rendering physician has opted out of 
Medicare; therefore, payment cannot be made. 
 
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 dental 
services provided by an opt-out provider on January 13, 2021, to April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on October 20, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request reconsideration for 
payment. 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 Drug Testing provided on October 20, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noninvasive ear or pulse oximetry for oxygen saturation 
coded as 94761 provided on September 14, 2021. 
 
You asked the Plan to pay for the noninvasive ear or pulse oximetry for oxygen saturation. You say that you 
would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says 
these services are bundled into other services already 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. 
 
In this case, the CPT Code Manual definition of code 94761 is noninvasive ear or pulse oximetry for oxygen 
saturation; multiple determinations (eg, during exercise). 
 
We looked at the file and Medicare rules. In this case, CPT code 94761 has a Status Code of "T" under the 
Physician Fee Schedule. This Status Code indicates that this service is only paid if there are no other services 
payable under the physician fee schedule billed on the same date by the same provider. As this is not the case, 
this service is bundled into services already paid. Based on this information, we decided that Medicare rules for 
coverage of the noninvasive ear or pulse oximetry for oxygen saturation have not been met. Therefore, we 
decided that the Plan does not have to pay for the noninvasive ear or pulse oximetry for oxygen saturation 
coded as 94761 provided on September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services rendered on 
September 15, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had no say in the 
ambulance provider the 911 operator called and were in no state to select an in-network provider. The Plan 
denied your request. The Plan says the copayment is the same for in-network and OON ambulance services, 
and the copayment applied 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 a $290 
copayment for per date of service regardless of the number of trips.  
 
 You have been asked to pay a $290 copayment for the ambulance services. The ambulance services fall within 
the Ambulance 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 waive the copayment for the 
ambulance services rendered on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the USB charge (K0108), electronic connection (E2311), harness (E2313), and expandable controller (E2377).
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the USB charge is not primarily medical in nature and the expandable controller, harness and electronic connection are not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 for the electronic connection, harness, and expandable controller. Our reviewer says that these items are not medically necessary. Our physician reviewer found that the member does have use of his hands and can operate and control the power options using the switches that are included in the basic wheelchair. The USB charge at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The expandable controller, harness and electronic connection are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the USB charge (K0108), electronic connection (E2311), harness (E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 13, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that supporting documents were sent as a 
reference to process the claim. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no approved 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 a home health visit provided on October 13, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator. 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.  
 
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 electrical bone growth stimulator. 
Our reviewer says that the requested device is not medically reasonable and necessary. Our physician reviewer 
found that you are a 66-year-old female being treated for lumbar radiculopathy; lumbar spondylosis with 
stenosis at L4-5; synovitis with dynamic instability at L4-5. You presented with cites low back, bilateral lower 
extremity pain and sensory change. The pain is an aching pain in her low back that radiates to the bilateral 
buttocks and posterior thighs. You note a sensory change in a similar distribution. You underwent lumbar 
decompression at L4-5 with Gill procedure bilaterally; instrumented interbody arthrodesis and posterolateral 
arthrodesis L4-5 on February 8, 2022.  
 
However, detailed documentation is not evident regarding of serial x-rays over a 3-month period evidencing no 
progressive healing to support the diagnosis of non-union at this time. There is no evidence in the available 
medical records that this patient would be considered at high risk for delayed fracture healing. A multilevel 
fusion is not demonstrated. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the requested electrical 
bone growth stimulator (E0748), in this case, 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 an electrical bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical bone growth stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services (64447) provided on August 23, 2021. 
 
You asked the Plan to pay for code 64447. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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 64447 
is a column II code to column I code 43753. 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 the injection services (64447) provided on August 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
August 5, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were billed because you went to 
emergency instead of your primary doctor. 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 $100 
copayment for each emergency room visit.  
 
You have been asked to pay a $100 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 on August 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99350) rendered by the out-of-network (OON) provider on December 23, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the home visit for the evaluation and management of an established patient (99350) 
rendered by the out-of-network (OON) provider on December 23, 2021.