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

 
We decided that the Plan does not have to pay for a genicular nerve block provided on February 10, 2022. 
 
You asked the Plan to pay for a genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block was not medically 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 pay for a genicular nerve block. Our reviewer says 
that a genicular nerve block is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are considered 
experimental/investigational in nature. The requested genicular nerve block is not reasonable and medically 
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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pay for a genicular nerve block provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for an automated external defibrillator (AED) provided on June 1, 2021. 
 
You asked the Plan to pay for the AED. You say that you did not know a prior authorization was needed. The 
Plan denied your request. The Plan says that the rendering provider is an OON provider and there was not a 
referring provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for an automated external defibrillator 
(AED) provided on June 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the genetic testing 
was not ordered/approved by the ordering provider.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Plan confirmed with the doctor's office that there was no order 
for genetic testing for this enrollee. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx (F1CDx) test (0037U) provided January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on January 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 25, 2022, to 
January 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network care. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services were not authorized or pre-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 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 inpatient hospital services provided on January 25, 
2022, to January 31, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says the member does not meet the Medicare criteria for 
admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 22, 2022 billed with 
codes 81479 and 81404. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 22, 2022 billed with codes 81479 and 81404.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood administration, collection of venous blood by 
venipuncture, inhalation treatment for acute airway obstruction, needles and procedure pack included in the 
inpatient bill for services provided on June 9, 2021, through June 27, 2021. 
 
You asked the Plan to pay for the routine services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says these are routine services. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services are the regular room, dietary and 
nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and 
the use of certain equipment and facilities for which a separate charge is not customarily made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the routine services have not been met. Specifically, the items and services at issue are considered 
routine and payment is bundled into the Room and Board charge. Therefore, we decided that the Plan does not 
have to pay for the blood administration, collection of venous blood by venipuncture, inhalation treatment for 
acute airway obstruction, needles and procedure pack included in the inpatient bill for services provided on 
June 9, 2021, through June 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies coded C1757, C1769, and C1887 provided on 
October 22, 2021, and October 23, 2021. 
 
You asked the Plan to pay for the supplies. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the items billed are 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 CPT code. 
 
We find that CPT code C1757, C1769, and C1887 is not supported in the medical record. Specifically, these 
codes have a status indicator of "N". This means these items are packaged in an ambulatory or outpatient 
surgery setting into the surgical procedure. The medical record indicates the devices, implants and supplies 
were utilized in an outpatient/ambulatory surgical surgery procedure. This means that these codes are not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the supplies coded C1757, 
C1769, and C1887 provided on October 22, 2021, and October 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on January 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services from March 27, 
2022, to March 28, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you believed you were 
going to an urgent care center rather than an emergency room. The Plan denied your request. The Plan says 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 $120 
copayment for each Medicare-covered emergency room visit for emergency room services.  
 
You have been asked to pay a $120 copayment for each Medicare-covered emergency room visit for 
emergency room services. Emergency room services fall within the Emergency care 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 emergency room services from March 27, 2022, to March 
28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory services provided from May 1, 
2022, to May 2, 2022. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that you were taken by 
ambulance to this facility where they did some tests and asked you if you wanted pain medication. You also 
say that you assumed everything was approved. The Plan denied your request. The Plan says you were 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 20% 
coinsurance for laboratory services in an outpatient hospital.  
 
You have been asked to pay 20% coinsurance for laboratory services in an outpatient hospital for laboratory 
services.  
 
 
 Claim Number: Date of Service: Allowed Amount: Coinsurance: 
820221270174655 May 1, 2022 $10.56 $2.11 
820221270174655 May 1, 2022 $6.70 $1.34 
820221270174655 May 1, 2022 $7.77 $1.55 
820221270174655 May 1, 2022 $3.43 $.86 
820221270174655 May 1, 2022 $6.01 $1.20 
820221270174655 May 1, 2022 $35.09 $7.02 
  $69.56 $14.08 
 
 
Laboratory services fall within the outpatient hospital 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 coinsurance for laboratory services provided from May 1, 2022, to May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit for the 
application of a multi-layer compression system of the leg provided from February 10, 2022, to March 28, 
2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit for the application of a multi-
layer compression system of the leg. You say that the enrollee is being charged a surgical copayment at an 
office visit for wound care. You also say that the enrollee is requesting a copayment correction. You also say 
that he does not want to be continually charged for a surgical copayment as this is an ongoing therapy for an 
unspecified amount of time. The Plan denied your request. The Plan says you were 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 $270 copayment for surgical services in an outpatient hospital.  
 
You have been asked to pay a $270 copayment for a hospital outpatient clinic visit for the application of a 
multi-layer compression system of the leg. A hospital outpatient clinic visit for the application of a multi-layer 
compression system of the leg falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 hospital outpatient clinic visit for the application of a multi-layer compression system of the 
leg provided from February 10, 2022, to March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient colonoscopy provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for an outpatient colonoscopy. You say that this should be a 
screening colonoscopy, not a diagnostic, therefore you should not have a copayment. The Plan denied your 
request. The Plan says the copayment applied was 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 $200 
copayment for an outpatient surgery.  
 
You have been asked to pay a $200 copayment for an outpatient colonoscopy. an outpatient colonoscopy falls 
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 outpatient 
colonoscopy provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed on July 1, 2021. 
 
You asked the Plan to pay for procedure code 99232. You say that the enrollee was seen by two different 
physicians under two different groups, and these are not incidental to each other. You say that medically 
necessary services were provided in good faith and the claim should be processed at the maximum amount 
allowed. The Plan denied your request. The Plan says there are no modifiers allowed with this code pair. 
  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 99232 
is a column II code to column I code 99233 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 procedure code 99232 billed on July 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 298 units of ambulance ground mileage (A0425) provided on 
September 5, 2020. 
 
You asked the Plan to pay for 298 units of ambulance mileage. You say that these services were necessary and 
should be paid. The Plan denied your request. The Plan says this claim line was not billed in accordance with 
Medicare rules. 
 The Plan must follow Medicare rules. Medicare rules say that services that have a claim line edit (i.e., an MAI 
indicator of 1) may have the same HCPCS/CPT code reported on separate lines of a claim. Each line of the 
claim with that code will be separately adjudicated against the MUE value for that code.   
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. This means that no more 
than 250 units of A0425 may be reported per line. You billed 298 units of this code on a single line, exceeding 
the MUE. Based on this information, we decided that Medicare rules for billing ambulance mileage have not 
been met. Therefore, we decided that the Plan does not have to pay for 298 units of ambulance ground mileage 
(A0425) provided on September 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the records does 
not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of laboratory services have not been 
met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided February 23, 2022.