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

 
We decided that the Plan does not have to pay for medical services provided from September 16, 2022, to 
October 3, 2022. 
 
You asked the Plan to pay for the medical services. You say that you were not aware that these services would 
not be covered and thought the claims would process under your out-of-network benefits. The Plan denied your 
request. The Plan says the doctor you saw opted out of Medicare, so these services cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for medical 
services provided from September 16, 2022, to October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection coded J7320, the arthrocentesis services coded 
20610, and the fluoroscopic guidance for needle placement coded 77002 provided on August 2, 2022. 
 
You asked the Plan to pay for the injection, the arthrocentesis services, and the fluoroscopic guidance for 
needle placement. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the services are not payable as billed. 
 
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 J7320, 20610, and 77002 are not supported in the medical record. Specifically, code 
J7320 is for Genvisc 850. The medical records indicate that Trivisc injection was administered. This means 
code J7320 is not supported. 
 
Code 20610 was billed with LT (left side) modifier; however, the diagnoses billed were M25.562 (pain in left 
knee) and M25.562 (pain in right knee). It is not appropriate to report unspecified, left, right or bilateral 
diagnosis codes when the procedure modifier on the claim line does not match the diagnosis code. 
 
Code 77002 was not reported with an appropriate primary procedure code for the same date of service. Since 
the primary procedure was denied, this add-on code is not payable as billed. 
 
Based on this information, we decided that Medicare rules for coverage of the hyaluronan injection, the 
arthrocentesis services, and the fluoroscopic guidance for needle placement have not been met. Therefore, we 
decided that the Plan does not have to pay for the injection coded J7320, the arthrocentesis services coded 
20610, and the fluoroscopic guidance for needle placement coded 77002 provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator provided on November 5, 
2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
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 automatic external defibrillator was not filed until November 7, 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 the automatic external defibrillator provided on 
November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a practitioner visit provided on June 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that you provided medically necessary services in 
good faith. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
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 a practitioner visit provided on June 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bilateral magnetic resonance imaging (MRI) of breast 
without and with contrast material (77049) provided on October 06, 2022. 
 
You asked the Plan to pay for the MRI. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says diagnosis code Z80.3 has a code first note and is not 
acceptable as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must comply with ICD-10-CM coding 
guidelines. The guidelines state that a manifestation code is not appropriate as a primary diagnosis as the etiology should be sequenced first. 
 
Specifically, this claim was billed with primary diagnosis code Z80.3. Diagnosis code Z80.3 has a code first 
note indicating that it is not an appropriate primary diagnosis.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for a bilateral 
magnetic resonance imaging (MRI) of breast without and with contrast material (77049) provided on October 
06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E06756) and segmental 
pneumatic appliances (E0673) provided August 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the most effective 
therapy for the prevention of deep vein thrombosis and its related complications during surgery is intermittent 
pneumatic compression therapy beginning in the preoperative area and continued until the enrollee is through 
with surgery. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 (E06756) and segmental pneumatic appliances (E0673) provided 
August 31, 2021, 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 provided on June 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you were given the correct diagnosis very 
late. The Plan denied your request. The Plan says this 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 laboratory services was not filed until October 19, 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 the laboratory services provided on June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided on January 13, 2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that the services of a surgical assistant 
were required and surgical assistant services are allowed for the procedures billed. The Plan denied your 
request. The Plan says the provider is not eligible to provide surgical assistant services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
on January 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of methadone; up to 7 additional day 
supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition 
to code for primary procedure coded G2078 provided on August 29, 2022. 
 
 
 You asked the Plan to pay for the take-home supply of methadone; up to 7 additional day supply (provision of 
the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary 
procedure. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
service billed is not covered. 
 
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 the 
take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-
enrolled opioid treatment program); list separately in addition to code for primary procedure is an add-on code 
and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the take-home 
supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid 
treatment program); list separately in addition to code for primary procedure coded G2078 provided on August 
29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Avise CTD genetic test (0312U) billed for date of service 
May 16, 2022. 
 
You asked the Plan to pay for Avise CTD genetic test. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests must 
undergo an application and technical assessment process through the MolDX contractor. Only approved tests 
will be reimbursed consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Avise CTD genetic test have not been met. Specifically, we determined that the genetic test at issue has not been approved through the MolDX contractor. Therefore, we decided that the Plan does not have 
to pay for Avise CTD genetic test (0312U) billed for date of service May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on 
September 28, 2022. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you called and were told that you 
had to have a prescription but that you would be reimbursed 80% of the price of this item.  You claim that this 
item should be authorized. The Plan denied your request. The Plan says purchased oxygen equipment is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered.  You purchased the oxygen equipment at 
issue instead of renting it. Based on this information, we decided that Medicare rules for coverage of the 
portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for 
the portable oxygen concentrator you purchased on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code 87086. You say that this test was medically necessary and is 
covered by Medicare. The Plan denied your request. The Plan says this service was not billed with a diagnosis 
which supports medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that there are certain diagnosis codes which support the medical necessity of code 87086. Any other 
codes are considered not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87086 have not been met. Specifically, the diagnosis code (C61) billed on this 
claim is not included on the list of appropriate diagnosis codes to support the medical necessity of CPT code 87086. Therefore, we decided that the Plan does not have to pay for procedure code 87086 billed for date of 
service September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided November 9, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical corrections. The Plan 
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply 
code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. The Plan made outreach to the ordering provider indicated to 
confirm that the DME items was ordered by the provider. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for the electrical stimulator supplies, 2 lead, per month (A4595) provided November 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine. 
 
You asked the Plan to pre-approve an MRI of the lower spine. 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. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lower spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the medical 
necessity of the requested MRI of the lumbar spine absent a red flag and absent a 6-week trial of physical 
therapy has not been established in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (86480, 87637) provided as part of a 
screening encounter for date for date of service October 12, 2022. 
 You asked the Plan to pay for laboratory services. You say that these services were necessary. The Plan denied 
your request. The Plan says these services were provided as part of a screening encounter, as shown by the 
diagnosis codes reported on this claim. These services are not covered when they are performed as a screening. 
 
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, laboratory services, 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 
laboratory services (86480, 87637) provided as part of a screening encounter for date for date of service 
October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor 
(CGM) provided on October 11, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the diagnosis code does not substantiate 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. Review of the file shows that the Plan has denied these supplies due to the 
diagnosis code not substantiating the service. However, the documentation is unclear why the diagnosis codes 
billed are inappropriate. The primary diagnosis code listed on the claim is E11.8 (type 2 diabetes mellitus with 
unspecified complications). No Medicare rules were provided to support why these supplies cannot be paid as 
billed. No other Plan denial rationale was provided. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) 
provided on October 11, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services (76817, 59430) provided on April 19, 2021, and 
December 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for services provided on April 19, 2021, and December 27, 2021. You say that these 
services were necessary, and you were informed they could be paid regardless of network status. The Plan 
denied your request. The Plan says the claim for the services provided on April 19, 2021, was not submitted 
timely and therefore cannot be processed. The services provided on December 27, 2021, were performed out-of-network, but the records do not support that this care was urgent/emergent or meets another exception for 
coverage. 
 
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. Medicare rules also 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 record shows that the claim for date of service April 19, 2021, was not filed until April 20, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. In 
addition, 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 services (76817, 59430) provided 
on April 19, 2021, and December 27, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for critical care services (99291) billed for date of service September 23, 
2021. 
 
You asked the Plan to pay for critical care services. You say that the services at issue were billed correctly. The 
Plan denied your request. The Plan says that you billed more than the maximum number of units of the 
procedure code at issue. 
 
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. Specifically, the Plan's denial rationale states that procedure code 99291 is 
limited to 1 unit. The Plan indicates that you have billed 2 units. The case record does not provide 
documentation that more than 1 unit was billed for the date of service at issue. It is the Plan's responsibility to 
substantiate its denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find 
in your favor. Therefore, we decided that the Plan has to pay for critical care services (99291) billed for date of 
service September 23, 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.