Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID test purchased January 4, 2022. 
 
You asked the Plan to pay for the at-home COVID test. You say that this should have been covered. You 
bought the COVID tests before the date the Plan said it would be covered. The Plan denied your request. The 
Plan says the at-home COVID test was not a covered benefit under Medicare at the time of purchase. At home 
COVID test coverage began on February 1, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID test is an OTC item. Therefore, we decided that the Plan does not have to pay for the at-home COVID 
test purchased January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Arthrocentesis provided on January 3, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Arthrocentesis. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Arthrocentesis provided on January 3, 2022 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided to you on February 9, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this is not 
covered for screening. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services are considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided to you on 
February 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related services 
provided on December 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that pneumatic compression devices are a proven 
treatment for deep venous thrombosis. The Plan denied your request. The Plan says the device is not covered 
by Medicare to prevent deep vein thrombosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. Items that are used for a preventative service or function are excluded from 
coverage. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and related 
services provided on December 22, 2021.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by code 97535-GO on dates December 27, 
2021, through December 30, 2021. We decided that the Plan does not have to pay for the other services at 
issue.  
 
You asked the Plan to pay for these billed outpatient therapy services. You say that this was billed correctly 
and should be paid. The Plan says that CPT code 97110 is identified as a mutually exclusive procedure to CPT 
92507, billed on the same days, December 29 and 30, 2021. CPT code 97530 is identified as a mutually 
exclusive procedure to CPT 92507, billed on the same days December 27, 2021, through December 31, 2021. 
CPT code 97535 is identified as a mutually exclusive procedure to CPT 97530, billed on the same days, 
December 27, 2021, through December 30, 2021. CPT code 97542 is identified as a mutually exclusive 
procedure to CPT 97530, billed on the same days, December 27, 2021, through December 29, 2021. All denied 
procedures were not billed with an appropriate modifier. 
 
We decided that the Plan has to pay for the services described by code 97535-GO on dates December 27, 
2021, through December 30, 2021.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The Plan indicated that code 97535 is mutually exclusive when billed with code 97530. We reviewed the PTP 
edits table and find that there is no edit between 97530 and 97535. As such, no NCCI modifier is needed to 
allow payment for the units of 97535 billed on these dates. Therefore, we decided that the Plan has to pay for 
the services described by code 97535-GO on dates December 27, 2021, through December 30, 2021.  
 
We also decided that the Plan does not have to pay for the other services at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT codes 97110 and 97530 are Column 2 codes in relation to Column 1 code 92507, billed on the same dates 
of service. Code 97542 is a Column 2 code to Column 1 code 97530. No NCCI modifiers were used to bypass 
the edits. Therefore, we decided that the Plan does not have to pay for the other services at issue. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 3, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for telehealth services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for telehealth services provided on January 3, 2022 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ankle-foot orthosis (L1932) provided 
on October 13, 2020. 
 
You asked the Plan to waive the coinsurance for an ankle-foot orthosis. You say that you were set up by the 
Plan to only pay a $25 copayment. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 20% 
coinsurance for each Medicare-covered prosthetic or orthotic device.  
 
You have been asked to pay $143.81, or 20% of the Medicare-allowed charge of $719.06, for an ankle-foot 
orthosis. An ankle-foot orthosis falls within the "Prosthetic Devices and Related 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 coinsurance for an ankle-foot orthosis (L1932) provided on October 13, 
2020.  
 
Your complaint about receiving erroneous or misleading information about your cost-sharing responsibilities 
from a representative of the Plan 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care services provided on February 15, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the observation care services. You say that your providers rely on the facility to 
obtain the proper authorization and the service was provided in good faith. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no approved 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 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 observation care services provided on 
February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Hospital Clinic services provided on September 
27, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Hospital Clinic services. 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 were not urgent or emergent. 
 
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 Outpatient Hospital Clinic services provided on 
September 27, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services (11719) provided February 24, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that this service should be covered. The Plan 
denied your request. The Plan says routine toenail trimming is non-covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry 
services (11719) provided February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of venous blood by venipuncture (36415) 
prothrombin time test (85610) provided April 17, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim was submitted on 4/22/20120 and 
is within timely filing. Documentation and original EOB have been attached. Please review for payment. The 
Plan denied your request. The Plan says the claim was submitted past the timely filing limitation 
 
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 November 25, 2021. 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 collection of venous blood by venipuncture (36415) 
prothrombin time test (85610) provided April 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on December 15, 2021. 
 
You asked the Plan to pay for CxBladder testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing identified by code 0012M is 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the CxBladder testing identified with 
code 0012M was performed. This service is strictly non-covered. Based on this information, we decided that 
Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder testing provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 25, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 home health visit provided on October 25, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99100) provided on October 28, 2021 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services 
(99100) provided on October 28, 2021
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the imaging services provided on February 10, 2022. 
 
You asked the Plan to pay for the imaging services. You say that you have provided the medical records for 
review and would like the claim reprocessed. The Plan denied your request. The Plan says that the rendering 
provider is an OON provider and there was no approved authorization. 
 
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 claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the imaging services provided on 
February 10, 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: 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 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 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. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services  are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on November 24, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 drug testing 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 the drug testing provided on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis provided on July 15, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the targeted genomic sequence analysis. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
 
 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 targeted genomic sequence analysis provided 
on July 15, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on February 
3, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the records support that this procedure was performed 
by your provider. The Plan denied your request. The Plan says it is bundled to another service billed on the 
same day. 
 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 70450 is a column II code to column I code 70496. 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 the computed 
tomography (CT) scan provided on February 3, 2022.