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

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81292) provided October 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81206, 81292) provided October 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 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 June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from December 15, 2021, to 
December 22, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says this provider 
is not supervised by any physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided from 
December 15, 2021, to December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0650, E0673). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the device was medically 
necessary. The Plan denied your request. The Plan says payment for this is included in payment to the facility 
and the device is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0650, E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral x-rays (D0220), 
and an unspecified preventive procedure (D1999) provided on February 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for a limited oral evaluation and intraoral x-rays has 
already been exhausted. The Plan also says an unspecified preventive procedure (D1999) is not covered by 
your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a limited oral evaluation and intraoral x-rays were exhausted on date of service February 
14, 2022. Though the Plan offers a dental benefit in excess of Medicare coverage, an unspecified preventive 
procedure is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral x-rays (D0220), and an unspecified preventive procedure (D1999) 
provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on December 30, 
2021. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that your claim was applied towards 
the out-of-network benefit. You also say you are being sent to collections over this. 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 50 
percent coinsurance for of the total allowed amount, per provider per day for each Medicare-covered primary 
care provider office visit.  
 
You have been asked to pay $143.50 in coinsurance, which is 50 percent of the allowed amount for an office 
visit ($287 allowed amount x 50% coinsurance = $143.50). 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 coinsurance for an office visit provided on December 30, 2021.  
 
Your complaint about the potentially poor customer service 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
purchased on January 10, 2022. 
 
You asked the Plan to pay for these services. You say that no Medicare providers had a machine. The Plan 
denied your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the continuous positive 
airway pressure (CPAP) device purchased on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on March 21, 2022. 
 
You asked the Plan to pay for an outpatient visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an outpatient visit provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, B-type Natriuretic Peptide (BNP) panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on November 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88313, 88312, 88305) provided September 30, 
2020. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until February 3, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for lab services (88313, 88312, 88305) provided September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulmonary genetic testing (81223, 81302 81345, 81407, 
81479, 81408) provided January 11, 2022. 
 
You asked the Plan to pay for the pulmonary genetic testing. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this service is non-covered for screening purposes. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for pulmonary 
genetic testing (81223, 81302 81345, 81407, 81479, 81408) provided January 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the lidocaine injection rendered on November 10, 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 that procedure code J2001 is inclusive to 20611. 
 
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 states that code J2001 is not separately payable because it is inclusive 
to code 20611; however, there are no active National Correct Coding Initiative (NCCI) procedure-to-procedure 
edits for this code pair. The Plan has not provided any documentation to support that the code is not payable as 
billed. Therefore, we decided that the Plan has to pay for the lidocaine injection rendered on November 10, 
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 GeneSight Psychotropic assay rendered on January 21, 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed 
adjacent to the CPT code for GeneSight testing. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX 
Z-Code. 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 GeneSight Psychotropic assay 
rendered on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (G0145) provided March 2, 2022. 
 
You asked the Plan to pay for the pathology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered at this frequency. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers this service every 2 years (or 23 
months past the month of the last covered exam) for low-risk women. 
 
We looked at the file and Medicare rules. The record does not show you are high-risk. The same screening test 
was performed in the past 23 months, on October 10, 2020. Based on this information, we decided that 
Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan 
does not have to pay for pathology services (G0145) provided March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic foot (L5980). 
 
You asked the Plan to pre-approve the replacement prosthetic foot. You say that a new foot is medically 
necessary. The Plan denied your request. The Plan says the current foot was provided in October 2021 and is 
still covered under warranty. Items under manufacturer's warranty are not covered for replacement or repair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an Ossur Proflex Foot. This prosthetic serves the same purpose as the requested 
replacement. Both foot prosthetics are K3 level. This foot is still covered under manufacturer's warranty. The records provided are from the prosthetist who has a financial interest in the claim outcome. These records alone 
are not sufficient to determine if the item is medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve a replacement prosthetic foot (L5980).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80076, 83540, 83550) provided December 14, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 80076, 83540, & 83550 is not supported in the medical record. Specifically, the 
services at issue were previously paid. The claim is a duplicate. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (80076, 83540, 83550) provided December 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have reached a point with physical 
therapy (PT) where daily skilled therapy based on clinical practice standards did not require daily skilled 
services. You did not respond to occupational therapy (OT) with material gains within a reasonable time frame 
indicating an impaired ability to respond to skilled therapy and likely a need for a prolonged time frame to 
improve with OT. Continued daily skilled therapy with OT is not medically necessary as you are unable to 
respond to the 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (J7507, J7517, Q0511, J7512) provided December 
30, 2021. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 codes J7507, J7517, Q0511, & J7512 are not supported in the medical record. Specifically, 
these codes have already been paid. Records do not support additional units. Based on this information, we 
decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the 
Plan does not have to pay for injections (J7507, J7517, Q0511, J7512) provided December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 23, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you feel insurance should cover all 
follow-up visits until cleared by the doctor. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each specialist visit.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 a specialist office visit provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2021. 
 
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 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 July 27, 2021.