Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on January 17, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that you were unaware that the provider was out of 
network. You also say that this office offered a special light therapy not offered in other offices. The Plan 
denied your request. The Plan says infrared therapy is not a payable benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 a spinal cord stimulator trial. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has 
not had recent conservative therapy and has not had a surgical consult. The request does not meet the criteria of 
a last or late resort. The request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81291) provided November 30, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR (5,10-methylenetetrahydrofolate 
reductase) gene analysis is non-covered. 
 
We looked at the file and Medicare rules. The test performed is non-covered under Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81291) provided November 30, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 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 January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 19, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the claim 
submitted was untimely and the submission did not meet the exception criteria guidelines outlined in Medicare 
Claims Processing Manual Chapter 1 Sections 70.1 and 70.4. 
 
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 physician's services was not filed until February 21, 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 physician's services provided on February 19, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on June 21, 2021, to June 
22, 2021. 
 
You asked the Plan to waive the copayment for ER visit. You say that you had to stay in the ER because no 
beds were available so you shouldn't be charged. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $90 
copayment for each ER visit.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall within the Emergency Care 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 ER visit provided on June 21, 2021, to June 22, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist visit and the coinsurance for 
the aflibercept injection provided on February 23, 2022. 
 
You asked the Plan to reduce the copayment for the specialist visit and the coinsurance for the aflibercept 
injection. You say that you should only be responsible for a $45 copayment. The Plan denied your request. The 
Plan says your cost share 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 20% 
coinsurance for Medicare Part B Prescription Drugs and a $45 copayment for physician services provided by a 
specialist.  
 
You have been asked to pay a $347.98 for the aflibercept injection. The allowed amount for this drug is 
$1739.92. 20% of $1739.92 is $347.98. Aflibercept falls within the Medicare Part B Prescription Drugs benefit 
category. You have also been asked to pay a $45 copayment for the specialist office visit. The specialist office 
visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefits 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 reduce the copayment for the specialist visit and the coinsurance for the  aflibercept 
injection provided on February 23, 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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 the enrollee is is functionally impaired but currently functioning at a home care level. 
He does not require intensive or complex rehabilitation services at this time. Although the enrollee has routine outpatient therapy needs, there is no indication for frequent physical medicine and rehabilitation oversight. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care provided on August 20, 2021, by an out-of-
network (OON) podiatrist. 
 
You asked the Plan to pay for the wound care. You say that you were not made aware of the enrollee's change 
of Plan on the date of service. The Plan denied your request. The Plan says the services were provided out-of-
network and were not 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 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 the wound care provided on August 20, 2021, by 
an out-of-network (OON) podiatrist.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept service (A0432) provided on July 9, 
2021. 
 
You asked the Plan to pay for the ambulance service. You say that you feel this charge should be eligible for 
coverage. You also say that the situation you experienced was traumatic. The Plan denied your request. The 
Plan says the ambulance service in this case is not covered by Medicare outside of New York State. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept service (A0432) provided on July 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services (A0427, A0425) 
provided on October 2, 2021. 
 
You asked the Plan to pay for ambulance services. You say that according to the enrollee's hospice facility, he 
revoked his hospice, and they will not be paying the bill. The Plan denied your request. The Plan says payment 
for this service is the responsibility of Original Medicare; the Plan is not responsible for payment of these 
services. 
 
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 date of service at issue in this appeal. Although it 
appears that the enrollee revoked hospice on the same date (October 2, 2021), and then returned later in the 
month, Original Medicare maintains responsibility for all Medicare-covered non-hospice services until the last 
day of the month when hospice was revoked. Therefore, we decided that the Plan does not have to pay for the 
ambulance transportation services (A0427, A0425) provided on October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sigmoidoscopy (45330-GC-59) provided on September 
9, 2021. 
 
You asked the Plan to pay for code 45330-GC-59. You say that the medical records support the use of modifier 
59 with code 45330. The Plan denied your request. The Plan says the medical records do not support the use of 
modifier 59 with code 45330. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 45330 is Sigmoidoscopy, flexible; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (separate 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 code 45330-GC-59. Our reviewer says that the medical 
records do not support the use of modifier 59 with code 45330. Our reviewer found the record indicates that the enrollee underwent laparoscopic colectomy with primary anastomosis and sigmoidoscopy was performed to 
assess the integrity of the anastomosis as part of that procedure.  The Coding guidelines indicate that coverage 
for the requested procedure is included in the nonendoscopic procedure code and is not available for separate 
coverage. The elements of the coverage criteria are not satisfied.  The requested service cannot be 
recommended. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 45330-GC-59 have not been met. Therefore, we decided that the Plan does 
not have to pay for the Sigmoidoscopy (45330-GC-59) provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foam rubber mattress. 
 
You asked the Plan to pre-approve a foam rubber mattress. You say that that your current mattress is tearing 
and causing an abrasion on the back of your knee. The Plan denied your request. The Plan says that you are not 
eligible for a new mattress. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no 
case can be less than five years. You received a foam rubber mattress on October 26, 2017, which is less than 
five years ago. Therefore, we decided that the Plan does not have to pre-approve a foam rubber mattress.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 2, 2021 billed 
with codes 81292, 81206, 81301,81321, 81235, 81162, 81295, 81298, 81317, 81402, 81194, and 81309. 
 
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 were not billed correctly. 
 
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 
September 2, 2021 billed with codes 81292, 81206, 81301,81321, 81235, 81162, 81295, 81298, 81317, 81402, 
81194, and 81309.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 16, 2021. 
 
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 billed correctly. 
 
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 
December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 27, 2021 billed 
with codes 81407, & 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was not correctly billed. 
 
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 
September 27, 2021 billed with codes 81407, & 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus antigen test provided on March 1, 2022. 
 
You asked the Plan to pay for the coronavirus antigen test. You say that it is required by the United States (US) 
government to have a negative coronavirus test within 24-hours in order to return to the US. You also say that 
this should be covered. The Plan denied your request. The Plan says coronavirus antigen test for the purpose of 
traveling is not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by the United States Government for the 
purposes of routine travel. Based on this information, we decided that Medicare rules for coverage of screening 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the coronavirus antigen 
test provided on March 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monoclonal antibody COVID-19 infusion and 
coronavirus vaccine administration provided on December 9, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the enrollee had tested positive for the 
coronavirus. You say that the infusions were given to alleviate the enrollee's symptoms. You also say that the 
services were medically necessary. The Plan denied your request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that health care providers who provide monoclonal 
antibody COVID-19 infusion administration to enrollees in a Medicare Advantage plan should submit claims 
to Original Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the monoclonal antibody COVID-19 infusion and coronavirus vaccine administration provided on 
December 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the chest provided on November 
8, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. 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 $15 
copayment for each standard X-ray service.  
 
You have been asked to pay a $15 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 X-rays of the chest provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the patient does not go to your laboratory, so  
out-of-network benefits are not being used as the participating doctor sends you the specimens to process. The 
Plan denied your request. The Plan says neither the rendering provider nor the referring provider are network 
providers with the Plan. The Plan also says that they have 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 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 March 7, 2022, by 
an out-of-network (OON) provider.