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

 
We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 the laboratory services provided on 
February 24, 2022, have been met. We find that payment for the lab services is not supported in the medical 
record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the 
physicians intent that the test be performed prior to services taking place. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on February 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on March 14, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you were advised you did not need to go to 
the emergency room. You also say that if you had known the claim would be denied, you would have gone. 
The Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
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 March 14, 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, no 
transport, (A0998) provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence garment, any type, (e.g., brief, diaper), each 
(A4520) purchased April 19, 2022. 
 
You asked the Plan to pay for incontinence supplies. You say that you had ordered the incontinence supplies 
not realizing you could order from over the counter. You are a double amputee and you have a prescription 
from your doctor. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence garment, any type, (e.g., 
brief, diaper), each (A4520) purchased April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making (99214) provided April 25, 2022. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that this service should be 
processed as a routine eye exam with no copayment. The Plan denied your request. The Plan says the billing 
and medical records support that this service was correctly processed as a medical eye exam. The copayment 
has been applied 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 Medicare-covered vision services.  
You have been asked to pay a $45 copayment for the medical eye exam. The medical eye exam falls within the 
Vision services benefit category. This exam was billed with a medical code 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 office or other outpatient visit for the evaluation and management of an 
established patient, which requires a medically appropriate history and/or examination and moderate level of 
medical decision making (99214) provided April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
3, 2022 to February 25, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with this denial and 
believe these services were medically necessary. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided February 3, 2022 to February 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services coded 88237, 88264, 88271, and 88275 
provided on September 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that these services cannot be billed with the diagnosis code billed. 
 
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. Review of the file shows that these services were billed with diagnosis code 
C90.00 (multiple myeloma not having achieved remission). The Plan states that the Local Coverage Article 
(LCA), A56013 states that these services are not payable with this diagnosis code. While the LCA does have a 
list of covered diagnosis codes, the LCA does not state that a diagnosis code not listed is not covered. No other 
rationale was provided by the Plan. Therefore, the Plan did not substantiate their denial. Therefore, we decided 
that the Plan has to pay for the laboratory services coded 88237, 88264, 88271, and 88275 provided on 
September 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full senior basic adjustable bed with wired remote 
(E1399) purchased July 14, 2021. 
 
You asked the Plan to pay for the adjustable bed. You say that this is for a refund on an adjustable bed that you 
bought for the enrollee. The Plan denied your request. The Plan says this bed does not meet the definition of 
DME and does not serve a medical purpose. The submitted information also did not include a standard written 
order from the prescriber or clinical notes. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the full senior basic adjustable bed with wired remote (E1399) 
purchased July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 4, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 4, 2022 by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 April 27, 2022 by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (97139) provided from January 17, 2022, to 
April 7, 2022. 
 
You asked the Plan to pay for the physician services. You say that these services should be covered as you pay 
a lot out-of-pocket for your insurance premium. The Plan denied your request. The Plan says since the provider 
is not certified for Medicare, the cost of the services is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the office visits (97139) provided from 
January 17, 2022, to April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 28, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 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, 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 October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 8, 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, 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 December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty walker with seat for the enrollee. 
 
You asked the Plan to pre-approve a heavy duty walker with seat. You say that the enrollee's current walker is 
not repairable and needs replaced. The Plan denied your request. The Plan says that the member does not meet 
the established criteria for a heavy-duty walker. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker is covered for beneficiaries 
who meet coverage criteria for a standard walker and who weigh more than 300 pounds and if the beneficiary 
weighs 300 pounds or less, it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The file indicates the enrollee does not meet the weight requirement 
for a heavy duty walker. Based on this information, we decided that Medicare rules for coverage of a heavy 
duty walker with seat have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
heavy duty walker with seat for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says payment for code 74176 is bundled into 
payment for code 74175. 
 
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 74176 
is a column II code to column I code 74175.  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 74176 billed for date of service May 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
appears to still be somewhat unstable for transfer and requires short-term additional acute care services that can 
be safely administered at the current facility until more stable and appropriate for transfer. The enrollee does 
not require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 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 24, 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 laboratory services related to end-stage renal disease 
(ESRD) provided on February 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85014, 82947, 82565, 84520) provided on 
February 1, 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 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 (85014, 82947, 82565, 84520) provided on February 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility discharge day management (99316) 
rendered by the out-of-network (OON) provider on March 16, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was rendered by an  
out-of-network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the nursing facility discharge day management (99316) rendered by the out-of-
network (OON) provider on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that please review the attached documents and 
reprocess the claim per the benefits of the Plan. The Plan denied your request. The Plan says payment for code 
83789 is bundled into payment for code G0481. 
 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 83789 
is a column II code to column I code G0481. 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 83789 billed for date of service March 16, 2022.