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

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 69990. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 69990 is bundled into payment for code 63030.  
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 69990 
is a column II code to column I code 63030. 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 69990 billed for date of service July 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the extremity ultrasound provided on May 
24, 2022. 
 
You asked the Plan to waive the copayment for the extremity ultrasound. You say that you are unable to pay 
for the services. The Plan denied your request. The Plan says this cost sharing was charged 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 
$137.27 copayment for diagnostic radiology services at an outpatient hospital. 
 
You have been asked to pay a $137.27 copayment for the extremity ultrasound. This item/service falls within 
the diagnostic radiology services at an outpatient hospital 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. The allowed amount for the ultrasound is $137.27. 
Since this is less than the $250 copayment per the EOC, you are only responsible for the lesser amount. 
Therefore, we decided that the Plan does not have to waive the copayment for the extremity ultrasound 
provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided May 15, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that A4595 is an accepted procedure 
code according to the Plan's durable medical equipment reference list (NCD 280.1). Please review carefully for 
claim processing. The Plan denied your request. The Plan says evidence of misrepresented service. 
 
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 a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the delivery ticket did include a carrier's tracking 
number, but the tracking was unable to be verified with USPS as of May 16, 2022, as the tracking only shows 
label created but not in system. The proof of delivery did not include an order number or details to corroborate 
the delivery ticket submitted. The proof of delivery is not itemized to indicate the specific supplies. There is no 
evidence of an established relationship between the enrollee and the referring physician. 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 electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) 
(A4595) provided May 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 11, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that cost sharing should be 
waived for COVID-19 testing related services. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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. Please note that the copayment only applies to the physician services. The actual testing 
itself is fully covered. Therefore, we decided that the Plan does not have to waive the copayment for the urgent 
care visit provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on May 05, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you only had a COVID-19 
test done. The Plan denied your request. The Plan says this cost sharing was charged 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 $65 
copayment for urgently needed services. 
 
You have been asked to pay a $65 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 urgent 
care visit provided on May 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 10, 2021, billed with 
codes 81227, 81401, and 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
May 10, 2021, billed with codes 81227, 81401, and 81225.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code G0453. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0453 is bundled into payment for code 95940.  
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 G0453 
is a column II code to column I code 95940. 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 G0453 billed for date of service March 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide hours. 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says these requested additional hours would be considered custodial 
care/personal care, and not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional hours. Our reviewer says 
that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found 
that you do not have any documented skilled nursing or skilled therapy needs. There is no evidence that home 
health aide services are required to assist in the treatment of illness or injury. As such, the requested home 
health aide services are not medically necessary or reasonable. 
 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 additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health aide hours.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified 
probe technique (U0003) provided May 11, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you ask for reconsideration of processing 
your claims for payment based on the current federal guidelines for COVID-19 testing and reimbursement. The 
Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the members terminal condition until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 28, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for infectious agent 
detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 
(Coronavirus disease [COVID-19]), amplified probe technique (U0003) provided May 11, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve a pre-transplant evaluation for renal transplantation. 
 
You asked the Plan to pre-approve the evaluation. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is a lack of current medical examination with regard to current renal and 
particularly cardiac status. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that 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 the evaluation. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that this referral is typically at the discretion of the provider (the nephrologist). The transplant center will 
then determine whether the enrollee is a candidate. There is no evidence that this patient actually has left 
ventricular dysfunction to suggest their heart disease would preclude them from transplantation. This patient 
meets criteria for referral to transplant center, who will determine initially, after reviewing records to consider 
patient for evaluation. If they choose to evaluate, they will decide whether patient is a suitable candidate. The 
transplant center screens records prior to starting an evaluation.  
 
 
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 evaluation have been met. Therefore, we decided that the Plan has to pre-
approve a pre-transplant evaluation for renal transplantation.  
 
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 procedure code 88305 billed for date of service September 
30, 2021. 
 You asked the Plan to pay for procedure code 88305. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this code is included in the skilled nursing facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88305 has a Professional/Technical indicator of 1. This means that CPT code 88305 has 
both a professional and technical component. In this case, CPT code 88305 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88305 billed for date of service September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring rendered on 
April 13, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 10 for 
telehealth services provided in the home. The file shows that this is the incorrect POS code for the services as 
rendered. Therefore, we decided that the Plan does not have to pay for the ambulatory continuous glucose 
monitoring rendered on April 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 29, 
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 July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care services provided on June 1, 2022. 
 
You asked the Plan to pay for initial observation care services. The Plan denied your request. The Plan says an 
Explanation of Benefits (EOB) is needed before this claim can be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the EOB from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for initial observation care services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for initial observation care services provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 11, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you are appealing the urgent 
care visit copayment based on a provision in the Families First Coronavirus Response Act, which eliminates 
beneficiary cost sharing for Covid-19 testing related services. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a digital, binaural hearing aid (V5261) provided on 
June 13, 2022. 
 
You asked the Plan to pay more for a digital, binaural hearing aid (V5261). You say that you  have previously 
not used your yearly allowances. You also say that you want a reconsideration payment against your device so 
that you are a contributing member of society and not another burden because of hearing loss. The Plan denied 
your request. The Plan says the benefit is $500 combined (in and out-of-network maximum benefit) coverage 
amount for both hearing aids (all types) up to two every three years. The Plan also says they have paid the $500 
on this claim. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan covers up to 
$500 combined for both hearing aids up to two every three years.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a digital, binaural hearing aid (V5261) have not been met. Therefore, we decided that the Plan does 
not have to pay more for a digital, binaural hearing aid (V5261) provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care on July 1, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 chiropractic care on July 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 19, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this was a 
lifesaving measure on the enrollee's behalf, and you do not understand why it has been denied. The Plan denied 
your request. The Plan says you were given glucose but were not taken to the hospital for evaluation. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74230 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 74230. You say that you cannot verify the place of service on 
this claim. The Plan denied your request. The Plan says this service was billed with an incorrect Place of 
Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are rendered to a patient who is 
registered inpatient or outpatient of a hospital, the correct POS code, regardless of where the face-to-face 
service occurs, is that of the appropriate inpatient hospital POS code or that of the appropriate outpatient hospital POS code.  
 
We looked at the file and Medicare rules. The records show that the enrollee was registered inpatient on the 
date in question. However, this service was billed with an outpatient POS code. Based on this information, we 
decided that Medicare rules for coverage of procedure code 74230 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 74230 billed for date of service April 29, 2022.