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

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 8, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the documentation supports the testing. The Plan 
denied your request. The Plan says the code is not separately reimbursed. 
 
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. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. 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 procedure 
code 83789 billed for date of service August 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee was admitted and treated 
accordingly with bilevel positive airway pressure (BIPAP) with average volume-assured pressure support 
(AVAPS). The enrollee does not show failure of BIPAP and hence does not meet criteria for a home ventilator 
per documentation or data provided. 
 
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 (E0466).
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 you are a fall risk and need additional therapy to get 
to baseline. The Plan denied your request. The Plan says your records do not show that you require the intensity 
of services of an IRF. The Plan says services may be provided at a lower level of care.  
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Axolotl (15271, Q4210, 15275). 
 
You asked the Plan to pre-approve Axolotl. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 pre-approve Axolotl. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee does not meet the criteria for coverage. The ulcer involves 
necrosis of the muscle layer. Necrotic tissue is present. There is clinical concern for infection with a plan to 
begin antibiotics once cultures are resulted. The review has determined that the items/services at issue in this case are not medically reasonable and 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 Axolotl have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Axolotl (15271, Q4210, 15275).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient provided on July 23, 2023. 
 
You asked the Plan to pay for initial hospital inpatient. You say that this service is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for initial hospital inpatient 
provided on July 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray services and outpatient rehabilitation 
service provided on July 26, 2023. 
 
You asked the Plan to waive the copayment for X-ray services and outpatient rehabilitation service. You say 
that you disagree with the copayment. 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 outpatient diagnostic tests/x-ray and a $5 copayment for outpatient rehabilitation service.  
 You have been asked to pay a $30 copayment for X-ray services and a $5 copayment for outpatient 
rehabilitation service. The total amount you are being asked to pay is $35 ($30 + $5 = $35). This item/service 
falls within the outpatient diagnostic tests/x-ray and outpatient rehabilitation service benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for X-ray services and outpatient rehabilitation service provided 
on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on June 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniGraf testing provided on December 20, 2022. 
 
You asked the Plan to pay for the OmniGraf testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The genetic testing in this case is not covered per the DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
OmniGraf testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
OmniGraf testing provided on December 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on June 19, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the extra diagnostic read is not payable.. 
 
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 70450-26 is not supported. The records show that the professional component of code 70450 was billed and paid for by the Plan. Two professional components of the same code, billed on the same date of service, is not payable in this case. Based on this information, we decided that Medicare rules for coverage of the billed code 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 April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies billed for date of 
service July 24, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the services. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee uses insulin or has a 
history of problematic hypoglycemia. Additionally, the billed date of service is inconsistent with the 
documentation provided.  Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor supplies billed for date of service July 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand x-ray billed with code 73130-LT for August 29, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says code 73130 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 73130-LT has an OPPS status indicator of 
Q1(s) and was billed with code 99283, which has an OPPS status indicator of V. Code 73130-LT is not 
separately payable when billed with a code with an OPPS status indicator of V. Therefore, we decided that the 
Plan does not have to pay for the hand x-ray billed with code 73130-LT for August 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to fully reimburse you for  the screening digital breast tomosynthesis, 
bilateral (77063) and screening mammography, bilateral (77067) provided August 4, 2023. 
 
You asked the Plan to fully reimburse you for  the diagnostic services. You say that you are appealing the 
decision to not fully reimburse you for the $381.00 payment. You know the provider is out of network, but this 
bill should not be subject to cost sharing because there are no in-network imaging providers in your area. 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 if you pay the entire amount yourself at the time you receive the care, ask us to pay you back for our share of the cost.  
 
You have asked for full reimbursement of $381.00 for the diagnostic services. The Plan has reimbursed to you 
the allowed amount of $181.86 ($53.12 for 77063 and $128.69 for 77069). The Plan has reimbursed their share 
of costs of the services performed. This item/service falls within the Breast cancer screening (mammograms) 
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 fully reimburse you for  the screening digital breast 
tomosynthesis, bilateral (77063) and screening mammography, bilateral (77067) provided August 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram and the laboratory services provided 
on May 09, 2023. 
 
You asked the Plan to pay for the electrocardiogram and the laboratory services. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
and the laboratory services provided on May 09, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance service provided on August 
24, 2023. 
 
You asked the Plan to waive the copayment for an ambulance service. You say that you cannot afford this 
copayment. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for an ambulance service. This item/service falls within the 
ambulance 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 waive the copayment for an ambulance 
service provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy and is the subject of ongoing clinical 
trials. Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service July 11, 
2023. 
  You asked the Plan to pay for procedure code 99070. You say that the attached medical records support the 
medical necessity of this claim. The Plan denied your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service July 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Synvisc injection provided on August 
4, 2023. 
 
You asked the Plan to waive the copayment for the Synvisc injection. You say that you feel the amount you 
were charged is excessive. You say that you should not be billed for same day surgery just for an injection. 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 20% 
coinsurance for each in-network Medicare-covered Part B drug and a $280 copayment for each in-network 
outpatient hospital and observation service. 
 
You have been asked to pay a total of $614.91 for the Synvisc injection.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
August 4, 2023 Synvisc injection $1,674.57 20% $334.91 
August 4, 2023 Outpatient surgery $1,600.00 $280 $280 
TOTAL:    $614.91 
 
These items/services fall within the Medicare Part B prescription drugs and services in an emergency 
department or outpatient clinic, such as observation services or outpatient surgery 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 Synvisc injection provided on August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87507) billed for date of service 
November 15, 2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have reported the service at issue 
correctly. The Plan denied your request. The Plan says records do not support the service billed. 
 
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 infectious-agent testing have been met. 
Specifically, medical records to support the service at issue have not been provided for review. Therefore, we 
decided that the Plan does not have to pay for infectious-agent testing (87507) billed for date of service 
November 15, 2022.