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

 
We decided that the Plan does not have to pay for procedure code A4220 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for procedure code A4220. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code A4220 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 code A4220 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4220 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4220 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4220 billed for date of service February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on February 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial nursing facility care. You say that the rendering physician is a hospitalist 
physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper 
authorization from the patient's insurance company. The Plan denied your request. The Plan says the member's 
Plan excludes coverage for this out-of-network service. 
 
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 initial nursing facility care provided on February 
14, 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 the home health services (99326) provided on February 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that it was the responsibility of the hospital 
staff to obtain authorization. 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 home health services (99326) provided on 
February 21, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided April 12, 
2022. 
 
You asked the Plan to pay for F1CDx testing. You say that the date-of-service should be reported as the date 
the specimen was collected. The Plan denied your request. The Plan says that this testing was medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of a molecular pathology test 
performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT, the date 
of service must be the date the test was performed if the criteria in the Medicare Rules section of this letter are 
met. 
 
We looked at the file and Medicare rules. In this case the laboratory test performed is considered an ADLT. 
The sample in this case was collected during a hospital outpatient counter. Therefore, the date-of-service was 
correctly reported as the date the test was performed, April 12, 2022. Based on this information, we decided 
that Medicare rules for coverage of F1CDx testing have been met. Therefore, we decided that the Plan has to 
pay for the FoundationOne CDx (F1CDx) testing (0037U) provided April 12, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 22, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the patient was not on hospice on the date 
of service. The Plan denied your request. The Plan says Original Medicare is responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 11, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29875 billed for date of service December 
15, 2021. 
 You asked the Plan to pay for procedure code 29875. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says payment for code 29875 is bundled into payment for 
code 29881. 
 
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 29875 
is a column II code to column I code 29881. 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 29875 billed for date of service December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) and closure of the lacrimal 
punctum (68761) provided on March 23, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that you are appealing the denial of the claim. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 outpatient office visit (99213) and closure of 
the lacrimal punctum (68761) provided on March 23, 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 an office visit, chemotherapy administration and treatment, 
and routine blood work with complete blood count provided on March 31, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for an office visit, chemotherapy, and blood work services. You say that you verified 
the enrollees benefits prior to rendering care, and you were told that the provider is in-network. You also say 
that you were told a referral and authorization is not required. The Plan denied your request. The Plan says both 
the provider and enrollee had ample time to request prior authorization for the services rendered to the enrollee. 
The services were neither urgent nor emergent, therefore, the decision to deny payment is correct. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit, chemotherapy administration and 
treatment, and routine blood work with complete blood count provided on March 31, 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 an office visit provided on May 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that 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 an office visit provided on May 16, 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 an office visit provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee benefited from the service provided and 
you would like reimbursement. 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 an office visit provided on January 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service October 
22, 2021. 
 
You asked the Plan to pay for procedure code 70450-26. You say that this claim was denied in error. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 16, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 70450-26 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 29, 2022 billed with 
codes 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. Services do not meet coverage 
requirements. 
 
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 
March 29, 2022 billed with codes 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351 and 
81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical procedure provided on March 11, 
2022. 
 
You asked the Plan to waive the copayment for a surgical procedure. You say that this amount would cause 
you financial distress. You say that the copayment is too high for the procedure, and you like it to be waived or 
changed. 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 a $350 
copayment for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  
 
 
  You have been asked to pay $318.40 for a surgical procedure, which is less than the standard $350 copayment. 
A surgical procedure falls within Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers, 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 a surgical procedure provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and lab services provided on January 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and lab services. You say that the services should be billed to a 
different insurance plan. The Plan denied your request. The Plan says the services were provided by an out-of-
network facility and was not urgent or emergent. The Plan also says the services 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.  
 
 
 Additionally, at the time of service, you were still enrolled in the Plan. This means the claim must be billed to 
this plan rather than the plan you are currently enrolled in. Therefore, we decided that the Plan does not have to 
pay for an office visit and lab services provided on January 18, 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 the nursing facility care provided on May 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. 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 nursing facility care provided on May 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on March 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for hospital services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for hospital services provided on March 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious agent detection by nucleic acid (DNA or RNA); 
gastrointestinal pathogen includes multiplex reverse transcription, when performed, and multiplex amplified 
probe technique, multiple types or subtypes, 12-25 targets (87507) provided on February 10, 2022. 
 
You asked the Plan to pay for laboratory service. You say that you believe these services were appropriate 
based on past medical history and you have submitted documentation for reconsideration. The Plan denied your 
request. The Plan says in the absence of clinical information, medical necessity and coverage cannot be 
determined. With the information the plan has, they cannot determine how the enrollee came to the servicing 
provider, or whether the services are medically necessary. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an infectious agent detection by 
nucleic acid, gastrointestinal pathogen have been met. After three or more attempts to obtain information, none 
were received. Therefore, we decided that the Plan does not have to pay for an infectious agent detection by 
nucleic acid (DNA or RNA); gastrointestinal pathogen includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87507) 
provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 18, 2021. 
 
You asked the Plan to pay for the medical services. You say that this service is not bundled and this claim 
should be reprocessed. The Plan denied your request. The Plan says the patient was on hospice on the date of 
service in question. 
 
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on November 18, 2021.