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

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
June 8, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes 99100 and 99140 is considered bundled 
and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99100 and 99140 is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's 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 August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on July 
25, 2022, billed with code 83789-59. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this code represents a 
higher complexity definitive drug test. The Plan denied your request. The Plan says this is specimen validity 
testing which is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on July 
25, 2022, billed with code 83789-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided from June 29, 2022, to 
July 6, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you thought the services were included in 
your benefits and feel you should not be responsible for the parenteral nutrition solution. The Plan denied your 
request. The Plan says this cost sharing was charged 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a total coinsurance of $88.08, which is 20% of the allowed amount for DME 
($440.40 x 20% = $88.08). This item/service falls within the durable medical equipment 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 DME provided from June 29, 
2022, to July 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code 85060. This means that 
the professional component of clinical laboratory codes for which separate payment may be made only if the 
physician interprets an abnormal smear for hospital inpatient. No TC billing is recognized because payment for 
the underlying clinical laboratory test is made to the hospital, generally through the Prospective Payment 
System (PPS) rate. Based on this information, we decided that Medicare rules for coverage of procedure code 
85060 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 85060 
billed for date of service August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for podiatry office visits provided from June 
1, 2022, to August 16, 2022. 
 
You asked the Plan to reduce the copayments for the podiatry office visits. You say that you were informed 
that your specialist copayment was only $15. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $30 
copayment for podiatry services.  
 
You have been asked to pay a $30 copayment for each of the podiatry office visits, for a total of $60. This 
item/service falls within the podiatry services 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 reduce the copayments 
for podiatry office visits provided from June 1, 2022, to August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93295 and 93296 billed on date of service April 21, 
2022. 
 
You asked the Plan to pay for codes 93295 and 93296. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the codes 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 93295 and 93296 are not supported in the medical record. Specifically, these services 
for remote interrogation are 90-day services, inclusive of all transmissions during that period which are then 
billed as a single service. Review of the file shows that these services were previously billed on April 5, 2022. 
Remote interrogation services 93295 and 93296 are 90-day services and may only be reported once during that 
period regardless of the number of interrogations performed. Ninety (90) days had not passed since these services were previously billed. This means the services billed for date of service April 21, 2022 is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of codes 93295 and 
93296 have not been met. Therefore, we decided that the Plan does not have to pay for codes 93295 and 93296 
billed on date of service April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cardiology specialist visit provided on 
September 13, 2022. 
 
You asked the Plan to reduce the copayment for a cardiology specialist visit. You say that you did not receive 
the echocardiogram on September 7, 2022, and your copayment should be $5, not $10. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $10 
copayment for cardiology specialist visits.  
 
You have been asked to pay a $10 copayment for a cardiology specialist visit. This item/service falls within the 
Help with Certain Chronic Conditions 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 reduce the copayment for a 
cardiology specialist visit provided on September 13, 2022.  
 Your complaint about not receiving an echocardiogram during your visit 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the home health services. You say that you have been needing home health 
services for over 9 months now and continuously keeps getting denied by the home health agency. The Plan 
denied your request. The Plan says coverage in denied because you are living outside of the covered services 
area. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan (bimatoprost) eye drops. 
 
You asked the Plan to pre-approve the Lumigan eye drops. You say that this is necessary due to the enrollee's 
glaucoma. The Plan denied your request. The Plan says self-administered eye drops are not covered by 
Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan (bimatoprost) eye 
drops.  
 
Benefits for the Lumigan eye drops may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 7, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 procedure code 70450 billed for date of service August 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. The enrollee has severe chronic obstructive pulmonary disease (COPD) and severe obesity and was 
recently hospitalized with pneumonia and congestive heart failure (CHF). Arterial blood gas (ABG) showed 
acute on chronic hypercarbic respiratory failure. There is a diagnosis of obstructive sleep apnea (OSA), and one 
note indicates the enrollee is on home bilevel positive airway pressure (BiPAP). There are no compliance reports. Settings are unknown. BiPAP is the appropriate treatment for this enrollee's chronic carbon dioxide 
(CO2) retention.  Changing the BiPAP setting to average volume-assured pressure support (AVAPS) may be of 
benefit. There is no evidence that BiPAP has failed in the outpatient setting. Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 it is felt that IRF is the best choice for this enrollee. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee can 
receive the care they need in another setting. 
 
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 was admitted to an acute hospital on 11/14/22 for a non-ST elevation 
heart attack, aspiration pneumonia, chronic kidney disease, and inclusion body myositis. He was discharged on 11/16 to his home.   
 
The enrollee is medically stable and does not need a rehabilitation physician's close supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no acute rehabilitation nursing needs identified. The enrollee does not need 3 hours a day 
x 5 days a week of therapies with multidisciplinary approach in an IRF. The therapies that the enrollee requires 
can be provided in a lower level of care. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428). 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover ambulance transports from a skilled nursing facility if admitted 
in a covered Part A stay. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
records show the enrollee is able to stand with the support of an assistive device and is not bed-bound. The 
enrollee does not have any acute conditions which require continuous monitoring. The review has determined 
that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, 
taxi, private car, or other type of vehicle) were contraindicated for this patient. The documentation does not 
support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a 
fully-equipped ambulance can provide for safe transport. The documentation does not support that the 
ambulance transport is medically reasonable and necessary for the patient. 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for non-emergency ambulance transportation (A0428).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing provided was medically necessary. 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 June 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-contrast CT scan provided on June 3, 2022. 
 
You asked the Plan to pay for the non-contrast CT scan. 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 for hospital-based services (inpatient/outpatient), 
it is expected that there should be an order for the 3D image. In the absence of the order for the 3D image, if 
the hospitals interpreting physician deems that the 3D interpretation is needed, he or she should clearly state in 
the interpretation the medical necessity for this separate service, in addition to the base procedure. 
 
We looked at the file and Medicare rules. Review of the file shows that there was no documentation of an order 
for this imaging service nor documentation by the interpreting physician that this interpretation was necessary. 
Based on this information, we decided that Medicare rules for coverage of the non-contrast CT scan have not 
been met. Therefore, we decided that the Plan does not have to pay for the non-contrast CT scan provided on 
June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunoassay for tumor antigen coded 86304 provided on 
July 27, 2022. 
 
You asked the Plan to pay for immunoassay for tumor antigen. 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 code 86304 is only covered when billed with 
certain diagnosis codes.  
 
We looked at the file and Medicare rules. Review of the file shows that this code was billed with diagnosis 
codes C50.911, C79.51, Z17.0, C50.919, and Z80.3. None of these diagnosis codes are listed as covered 
diagnosis codes for the service rendered. This means this code is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of immunoassay for tumor antigen have not been 
met. Therefore, we decided that the Plan does not have to pay for immunoassay for tumor antigen coded 86304 
provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210 x2) and a consultation with 
an oral surgeon (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for one extraction to be provided by an oral surgeon has been approved. Although the 
request was initiated in 2022 when services provided by an oral surgeon were not covered, this is now a 
covered benefit in 2023. However, the benefit is still limited to one extraction and that will be exhausted once 
the approved service is completed. Therefore, we decided that the Plan does not have to pre-approve surgical 
extractions (D7210 x2) and a consultation with an oral surgeon (D0150).