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

 
We decided that the Plan does not have to pay for office visit provided on May 04, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration stating claim denied 
incorrectly as they are in-network. The Plan denied your request. The Plan says the enrollees network primary 
care physician (PCP) or plan must give the enrollee approval in advance before the enrollee can use providers 
not in the plan's network. This is call giving the enrollee a "referral." 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visit provided on May 04, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 29, 2021, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes cannot be reimbursed. 
 
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 the denied codes is: 
 
CPT 33534: 
 
Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts 
 
CPT 33508: 
 
Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List 
separately in addition to code for primary procedure) 
 
 
 CPT 33518: 
 
Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition 
to code for primary procedure) 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 33534, the 
operative report describes two venous grafts performed. To cite the report "Median sternotomy incision was 
made while the Endo vein harvesting system was used to harvest the greater saphenous vein from the right 
leg.  The was of reasonably good quality.  The left internal mammary was harvested from underneath the left 
side of the chest and was somewhat small but had excellent flow".  In this case, CPT 33534 cannot be verified. 
In terms of CPT 33508, this procedure is documented in the operative report, however, primary procedure 
codes reported cannot be verified, therefore this procedure would not covered. As for CPT 33518, this 
procedure is an "add on" code for CPT 33534, and in this case the primary procedure code cannot be verified in 
operative report, and therefore this procedure cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the frames and lenses provided on June 7, 2022. 
 
You asked the Plan to reimburse frames and lenses. You say that you want a refund on the glasses. The Plan 
denied your request. The Plan says the member is responsible for any amount over the $250 credit allowance. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a one-time $250 benefit toward the purchase and fitting of eyeglasses and pair of 
lenses or contact lenses per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that you are responsible for any amount over the 
one-time $250 credit towards the purchases of your frames and lenses. The record shows that you purchased 
the frames and lenses on June 7, 2022, for $1,274. After the $250 benefit and an in-network discount, your 
responsibility is $819.20. Based on this information, we decided that the Plan's rules for coverage of frames 
and lenses have not been met. Therefore, we decided that the Plan does not have to reimburse the frames and 
lenses provided on June 7, 2022.  
 
Your complaint about being unsatisfied with the glasses is not a valid appeal for medical coverage. That is not 
in our jurisdiction. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says no clinical records by the physician were provided. 
 
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 laboratory services provided on June 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (code 80307) billed for date of 
service May 18, 2022. 
 
You asked the Plan to pay for code 80307. You say that you have provided medical records to show the 
medical necessity of this service. The Plan denied your request. The Plan says it has already received a claim 
for one unit of code 80307 for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that only one code for presumptive drug testing may 
be paid per day.  In this case, the Plan has already received a claim for code 80307 from the patient's recovery 
clinic.  Your submission of code 80307 represents a second unit of this code, and a second unit of this code is 
not payable per Medicare billing rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 80307 have not been met. Therefore, we decided that the Plan does not have to pay for 
presumptive drug testing (code 80307) billed for date of service May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on April 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 genetic testing provided on April 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 6, 2022 billed with 
codes 81276, 81275, 81206, and 81301. 
 
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 the services are not covered. 
 
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 
February 6, 2022 billed with codes 81276, 81275, 81206, and 81301.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223-AI-FS billed for date of service May 18, 2022. 
 
You asked the Plan to pay for code 99223-AI-FS. You say that you billed this code with the AI modifier, so it 
should be paid separately. The Plan denied your request. The Plan says an evaluation and management (E/M) 
visit was already paid on this date of service to another cardiology provider in the same group.  Therefore, this 
code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that two E/M visits on the same day by the same 
provider or providers of the same specialty within the same group are not payable unless the visits are 
unrelated.  In this case, the same medical group and specialty provided two E/M visits on the same day.  
Although you billed with the AI modifier, this is not a payment modifier.  You did not bill with a modifier that 
would indicate that the visits were unrelated. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99223-AI-FS have not been met. Therefore, we decided that the Plan does not have to pay for 
code 99223-AI-FS billed for date of service May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72040 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 72040. You say that this should be covered The Plan denied your 
request. The Plan says payment for code 72040 is bundled into payment for code 72052. 
 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 72040 
is a column II code to column I code 72052. 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 72040 billed for date of service April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on October 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says records do not show that this service was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of lab services (0037U) provided on 
October 7, 2021. have been met. No clinical notes were provided to support this service. The only records provided were lab results. Therefore, we decided that the Plan does not have to pay for lab services (0037U) 
provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service June 4, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this should be paid for The Plan denied your 
request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 
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 70544 is a column II code to column I code 70551. 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 70544 billed for date of service June 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0035 billed for date of service April 3, 
2022, to May 2, 2022. 
 
You asked the Plan to pay for procedure code H0035. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H0035 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0035 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0035 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0035 billed for date of service April 3, 2022, to May 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065-26 billed for date of service May 13, 
2022. 
 You asked the Plan to pay for procedure code 77065-26. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065-26 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. It appears that you billed one unit for the left side and one for the right side instead 
of a single unit indicating that the procedure was performed bilaterally. Based on this information, we decided 
that Medicare rules for coverage of procedure code 77065-26 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 77065-26 billed for date of service May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2022, to June 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 23, 2022, to June 
22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 31, 2022. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says either Original Medicare or hospice is 
responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was independent and active, lives alone 
has a goal of returning home independently. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.