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

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on March 3, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test was medically necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the unique test 
identifier is missing. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim information does not show that the testing was billed as required. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne testing provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued primary care physician (PCP) services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON PCP services. You say that it is felt that the enrollee should be 
allowed to continue with the current PCP. The Plan denied your request. The Plan says one visit has been 
approved, but beyond this visit, an in-network PCP must be used. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON PCP services. Our reviewer says that the documentation does not 
support the medical necessity of continued care with the OON PCP. Our physician reviewer found the enrollee 
is 68 years old with a past medical history of hypertension, chronic kidney disease, gout and anxiety.  
 Coverage for out of network primary care physician office visits has been requested, and the Plan has approved 
one visit to allow a transition to a network provider. 
 
Based on the medical records provided, there is no documentation that the enrollee's conditions or treatment 
plan are so complex or unique as to require out of network care. There is no indication that an in-network 
providers would be unable to meet this enrollee's care needs.  
 
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 OON PCP services have not been met.  
 
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 the OON PCP services. Therefore, we decided that the 
Plan does not have to pre-approve continued primary care physician (PCP) services to be provided by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 23, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493, 64494 and 64495 billed for date of 
service May 18, 2021. 
  You asked the Plan to pay for procedure code 64493, 64494 and 64495. You say that the documentation 
supports the services billed and the claim should be reviewed for payment. The Plan denied your request. The 
Plan says payment for code 64493, 64494 and 64495 are bundled into payment for code 64640. 
 
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 64493 
is a column II code to column I code 64640. This code has not been billed with an appropriate modifier to 
bypass the edit. We have also confirmed that codes 64494 and 64495 are column II code to column I code 
64640 with a modifier indicator of 0. The column II codes are 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 codes 64493, 64494 and 64495 billed for date of service May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for anti-reflective coating (V2750) and frames (V2020) provided on 
December 2, 2021. 
 
You asked the Plan to pay for anti-reflective coating (V2750) and frames (V2020). You say that these glasses 
were needed due to a change of vision after you had cancer in your left eye. The Plan denied your request. The 
Plan says that You are responsible for this charge. The Plan also says that they have paid the maximum amount 
covered by your plan for this service. 
 
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 Plan failed to provide verification as to when the enrollee met the non-
Medicare covered eyewear allowance. Without any explanation of benefits or any other verification, we cannot 
determine that the enrollee actually met the $250 non-Medicare covered eyewear allowance. Therefore, we 
decided that the Plan has to pay for anti-reflective coating (V2750) and frames (V2020) provided on December 
2, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services billed for service on October 29, 
2021. 
 
You asked the Plan to pay for the billed services. You say that a copy of the emergency department report was 
provided The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not include 
the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care 
services billed for service on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam by a pathologist (88305) provided on April 
29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that these services were medically necessary and 
were referred by a physician. The Plan denied your request. The Plan says out-of-network services are only 
covered in certain limited circumstances. The requested services were referred by an out-of-network provider 
and no prior authorization was requested. 
 
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/referred 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 tissue exam by a pathologist 
(88305) provided on April 29, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 71046. 
 
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 71045 is a column II code to column I code 71046. 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 71045 billed for date of service June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 88305. You say that this service was billed correctly. The Plan 
denied your request. The Plan says code 88305 has a professional component and a technical component. The 
payment for the technical component is included in the payment to the facility. This service cannot be paid 
without a modifier indicating that only payment for the professional component is requested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT code 88305 is a physician pathology service which has both a professional component (PC) 
and a technical component. This service was not billed with modifier 26 to indicate that only the professional 
component payment is requested. This means that payment is requested for both the PC and TC of this service. 
However, this service was provided to an enrollee who was in an outpatient hospital setting at the time the 
sample was collected, which means that the TC component is bundled into the facility payment. The TC 
portion of this service is not separately payable, and therefore this service is not supported as billed. 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 
March 2, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the laparoscopy (43279) provided on October 14, 2021. 
 
You asked the Plan to pay for the laparoscopy (43279). You say that the operative report supports the 
procedure and the claim should be processed accordingly. The Plan denied your request. The Plan says that 
procedure code 43282 was approved and procedure code 43279 is not supported by the medical records 
submitted. 
 
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 43279 is laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laparoscopy (43279). Our reviewer says that the medical 
documentation does support the use of procedure code 43279. Our reviewer found that this was done without 
the additional fundoplasty but can still be captured with procedure code 43279. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laparoscopy (43279) have been met. Therefore, we decided that the Plan has 
to pay for the laparoscopy (43279) provided on October 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 7, 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 procedure code 27134 is not supported. 
 
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 27134 is revision of total hip arthroplasty; both 
components, with or without autograft or allograft. 
 
We find that CPT code 27134 is not supported in the medical record. Specifically, there is no documentation of 
a revision of total hip arthroplasty for both components, with or without allograft. 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 pay for the surgical services rendered on May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 27, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
billed with the appropriate identifier. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the testing provided on March 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids, digital, binaural, behind the ear (V5261) 
provided July 7, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were told you could go anywhere to purchase 
hearing aids. The Plan denied your request. The Plan says that there is no coverage if Hearing Aids or related 
services are received from outside of the Plan's hearing network. The hearing benefit is not covered if the 
services are not registered in advance. 
 
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 pays for 
hearing aids only when purchased through the Plans Hearing vendor.  
 
We looked at the file and the Plan's rules. In this case hearing aids were purchased out-of-network without prior 
approval. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to pay for the hearing aids, digital, binaural, 
behind the ear (V5261) provided July 7, 2021.  
 Your complaint about potentially being provided misinformation by a plan representative is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 22, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were only in the office for 5 
minutes. 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 $45 
copayment for each in-network Medicare-covered visit with a specialist. 
 
You have been asked to pay a $45 copayment for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 office visit provided on April 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 1, 2019, through July 
5, 2019, at DRG 853. 
 
  You asked the Plan to pay for inpatient services at DRG 853. You say that DRG 853 was correctly billed due to 
the presence of an altered mental state and documentation of metabolic encephalopathy. You say that medically 
appropriate services were rendered, and the denial of payment should be overturned. The Plan denied your 
request. The Plan says DRG 853 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code G93.41, defined as metabolic 
encephalopathy. 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 inpatient services at DRG 
853. Our reviewer says that the documentation does not support diagnosis code G93.41.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from July 1, 2019, through July 5, 2019, at DRG 853.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on January 14, 
2022. 
 
  You asked the Plan to pay for moderate sedation services (99153). You say that the claim was billed using the 
correct place of service and the medical records substantiate the place of service. You say that the decision 
should be reconsidered, and payment issued. The Plan denied your request. The Plan says CPT code 99153 
may not be paid if furnished to hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided 
on January 14, 2022.