Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infectious Disease Bacterial and Fungal Assay (CPT code(s): 
87481, 87801, and 87797) provided on July 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request for the Infectious Disease Bacterial and Fungal Assay does not meet 
Medicare rules as reasonable and necessary. The review of the medical literature and clinical practice 
guidelines do not support PCR testing as a first line approach for evaluation of onychomycosis and it is not widely accepted as standard of care. The review has determined that the items/services at issue in this case are 
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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for Infectious Disease Bacterial and Fungal Assay (CPT code(s): 87481, 87801, and 
87797) provided on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on July 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service and the use of the -59 modifier are not supported. 
 
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 the denied codes is: 
 
CPT 36215: 
 
Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a 
vascular family 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation  
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found CPT 36215 would be considered 
inclusive to CPT 36902. In this case, the procedure report does support a suspected arterial inflow problem, 
however, the documentation states "Because of a weak flow, fistula was accessed in the opposite direction 
using 6Fr sheath towards the arterial inflow". The documentation does not support this procedure as a separate 
procedure. In terms of CPT 75710, as the procedure report does not support CPT 36215, CPT 75710 also 
cannot be covered. 
 
We looked at this coder'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 surgical services provided to the enrollee on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Keytruda (pembrolizumab) provided with Mvasi on 
September 22, 2021. 
 
You asked the Plan to pay for the Keytruda/Mvasi combination therapy. You say that this treatment was 
necessary for the enrollee's cancer. The Plan denied your request. The Plan says these drugs are not supported 
as treatment for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda/Mvasi combination therapy. 
Our reviewer says that the medications provided for the enrollee's condition are not considered reasonable and 
necessary. Our physician reviewer found the enrollee has recurrent high-grade serous ovarian cancer. She has 
had several prior treatments with gemcitabine and cisplatin. She had progression on bevacizumab therapy. 
Pembrolizumab (Keytruda) is not FDA-approved for the treatment of recurrent ovarian cancer. There is no 
documentation of high tumor mutation burden (TMB), high microsatellite instability (MSI) or deficiency of 
mismatch repair (dMMR)to support use based on these markers. Use is not supported by major drug compendia 
or the medical literature. The service is not reasonable or medically 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 the Keytruda/Mvasi combination therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for the Keytruda (pembrolizumab) provided with Mvasi on 
September 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on September 30, 
2021, by a provider not certified with Medicare, Full Spectrum Emergency Center. 
 
You asked the Plan to pay for the emergency room services. You say that you presented your health insurance 
card when you were seen at this facility, and you were told that they accepted Medicare. You state that you 
were not told they were out-of-network. You state you were sick at the time with COVID-19, you had fallen 
earlier and were in horrendous pain. You state that you chose this facility because they were giving infusions 
for COVID-19 treatment. The Plan denied your request. The Plan says they found twenty-two (22) Medicare-
certified emergency rooms within twenty (20) miles of your home. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the emergency room services have not been met. Medicare 
guidance says to receive payment for covered Medicare items or services from either Medicare (in the case of 
an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must 
be enrolled in the Medicare program. The provider you saw on September 30, 2021, is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the emergency room services 
provided on September 30, 2021, by a provider not certified with Medicare, Full Spectrum Emergency Center.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (CPT code(s): 99100) and 01830) provided on 
October 27, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 code 99100 is assigned a status code = B. Payment for covered services are always bundled into payment 
for other services not specified. As the claim was billed with a CPT code which is always bundled.  
CPT code 01830-AA-P3 (152 Units) remains not supported. The submitted medical records indicate 
Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand 
joints; not otherwise specified was performed; however, the records do not support the number of units billed; 
therefore, the billed service cannot be verified. 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 
anesthesia (CPT code(s): 99100) and 01830) provided on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (CPT code(s): 81291 and 
81479) provided on May 27, 2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that the claim should be paid. The 
Plan denied your request. The Plan says the services were not medically necessary. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the GeneSight Psychotropic testing. Our 
physician reviewer found the case file contains a GeneSight Order Medical Necessity Documentation form, and 
the results of the GeneSight testing. The documentation is insufficient to support that the GeneSight genetic 
testing was medically reasonable and necessary for the enrollee in this case. 
 
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 GeneSight Psychotropic testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the GeneSight Psychotropic testing (CPT code(s): 81291 and 81479) 
provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on December 11, 2020, 
through December 18, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services are supported. The Plan denied 
your request. The Plan says payment of DRG 177 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with inpatient hospital care provided on December 11, 
2020, through December 18, 2020. 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 inpatient 
hospital care. Our physician reviewer found there was no evidence of a gram-negative bacteria to support 
reporting gram negative pneumonia. There was no further diagnostic testing done such as sputum gram stains, 
sputum cultures or blood cultures growing a gram- negative organism available for review or positive urine 
antigen test for Legionella available for review. CTA of the chest, "Irregular opacifications involving both 
lungs, especially the posterior aspect of the lower lobes which could be atelectasis, infiltrate/pneumonia." The 
review has determined that DRG 177 was not supported by the records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided on December 11, 2020, through December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME purchased on December 7, 2021, from an out-of-
network provider. 
 
You asked the Plan to pay for the DME. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says this provider is out-of-network, the services were not 
referred by a network provider, and the services were 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 the DME purchased on December 7, 2021, from 
an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014, 92015) provided on 
August 25, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you feel you should not be 
responsible for this cost. The Plan denied your request. The Plan says this claim was processed correctly, and 
your copayment was assessed in accordance with your contract. The Plan also says they are not assessing a cost 
to you for the eye refraction, as this service was included with the eye exam. 
 
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 $45 copayment for Medicare-covered services to diagnose and/or treat a disease or condition of the eye.  
 
You have been asked to pay a $45 copayment for the eye exam. Documentation shows that the eye exam was 
provided to evaluate cataracts, and therefore this service falls within the Medicare-covered services to diagnose 
and/or treat a disease or condition of the eye 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 the eye exam (92014, 92015) provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused oral evaluation (D0140), and pulp 
vitality test (D0460) provided on November 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says 1 problem focused oral evaluation is covered every 12 months. The Plan says that 
the frequency limit has been exceeded. The Plan also says that pulp vitality test is not a covered service. 
 
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 and problem focused oral evaluation is 
covered once every 12 months, the frequency limit has been exceeded. The record shows that the Plan paid for this service that you received on June 15, 2021. Additionally, pulp vitality test is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused oral 
evaluation (D0140), and pulp vitality test (D0460) provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 87150) provided on 
August 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 87150 (11 
Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory setting POS 81; however, the submitted medical documentation and/or claim history 
indicates that the specimen was obtained in an Office, POS 11. Also, the laboratory results submitted indicate 
the specimen was collected on August 9, 2021, and received by the lab on August 11, 2021. It is noted multiple 
attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code 87150) provided on August 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from August 6, 2021, through August 10, 
2021, provided by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that you rendered treatment to the patient in 
good faith that the services will get reimbursed. The Plan denied your request. The Plan says this provider is 
out-of-network, the services were not referred by a network provider, and the services were 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 SNF care provided from August 6, 2021, through 
August 10, 2021, provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from September 22, 2021, to 
September 24, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the services billed are not covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided from September 22, 2021, to September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with a naturopathic doctor. 
 
You asked the Plan to pre-approve office visits with a naturopathic doctor. You say that you have been seeing 
this provider for five years and she provides the best care. You say that your current primary care physician 
gives care advice that doesn't match your beliefs and you have to pay out-of-pocket to see your requested 
provider. The Plan denied your request. The Plan says naturopathic services are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal services naturopathic services. Therefore, we decided that the Plan does not 
have to pre-approve office visits with a naturopathic doctor.  
 
Please note, naturopathic services may be available under your Wallet Benefit. Contact the Plan for additional 
information regarding those benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided from June 22, 2021, through 
September 27, 2021, by a provider not certified with Medicare. 
 
You asked the Plan to pay for the office services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says this provider does not participate in the Medicare 
program. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the office services have not been met. Medicare guidance says to 
receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) 
or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the 
Medicare program. The provider you saw from June 22, 2021, through September 27, 2021, is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the office services 
provided from June 22, 2021, through September 27, 2021, by a provider not certified with Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on December 9, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on December 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unilateral breast ultrasound (76641) rendered by the out-
of-network (OON) provider on December 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the unilateral breast ultrasound (76641) rendered by the out-of-network (OON) 
provider on December 17, 2021.