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

 
We decided that the Plan does not have to pre-approve the infusion supplies not used with external infusion 
pump, per cassette or bag (list drugs separately) (A4223). 
 
You asked the Plan to pre-approve the infusion supplies. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says per Medicare guidelines, this 
item s not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at this the file and Medicare rules. Since the disposable equipment used for this infusion is not 
covered by Medicare, the request for A4223 is denied. Per Medicare rules home infusion can be covered but 
only with external infusion pumps (which do not include disposable delivery systems as being requested in this 
case. Based on this information, we decided that Medicare rules for coverage of the infusion supplies have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the infusion supplies not used with 
external infusion pump, per cassette or bag (list drugs separately) (A4223).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 85025) provided on May 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80053, & 85025 are not supported in the medical record. Specifically, the records do 
not include a physician order for the billed tests. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (80053, 85025) provided on May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network durable medical 
equipment (DME) provider. 
 
You asked the Plan to pre-approve these services. You say that no alternative pumps are available. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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. The Plan confirmed that they have providers available with the specific item the enrollee needs. 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 a 
referral to an out-of-network durable medical equipment (DME) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 23, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 laboratory services 
provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the chiropractic services. You say that this has been an ongoing problem 
and since you have had no relief you went out of network and found a provider that is actually helping you. 
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 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 
the chiropractic services to be provided 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 new patient outpatient office visit (99205) provided on 
August 29, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that  you have attached the medical records to show that 
the services were medically necessary. Please review and reconsider previous denial. 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 new patient outpatient office visit (99205) 
provided on August 29, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the duplex scan provided on August 28, 
2023. 
 
You asked the Plan to reduce the copayment for the duplex scan. You say that the EOC is misleading. 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 $100 
copayment for Medicare-covered vascular studies, including a duplex scan. 
 
You have been asked to pay a $100 copayment for the duplex scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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 copayment 
for the duplex scan provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92004) and determination of 
refractive state (92015) provided on June 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ophthalmology services. You say that please pay this enrollees claim. The 
enrollee was in a nursing home and cannot travel distances. 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 generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 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 ophthalmological services (92004) and 
determination of refractive state (92015) provided on June 8, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on August 22, 
2023. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that this 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 a psychiatric diagnostic 
evaluation provided on August 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on July 22, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
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 99285 is not supported in the medical record. Specifically, diagnosis I82.401 Acute 
embolism and thrombosis of unspecified deep veins of right lower extremity and I824.02 Acute embolism and 
thrombosis of unspecified deep veins of left lower extremity were both billed. There is a more appropriate 
bilateral diagnosis code for this service. Based on this information, we decided that Medicare rules for 
coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have 
to pay for emergency room services (99285) provided on July 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on June 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for podiatry services. You say that you are in network. The Plan denied your request. 
The Plan says that their original decision to deny payment was 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 podiatry services provided on June 16, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20550 billed for date of service June 28, 
2023. 
 You asked the Plan to pay for procedure code 20550. You say that 20550 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says payment for code 20550 is 
bundled into payment for code 64420. 
 
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 20550 
is a column II code to column I code 64420. 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 20550 billed for date of service June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 25, 2022, billed with 
procedure code 0315U. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the practitioner 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on July 25, 2022, billed with procedure code 0315U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 4, 2023, billed with 
procedure code 99307-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the service at issue was not billed with the 
required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 10160 
provided on June 27, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
July 4, 2023, billed with procedure code 99307-25.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Guardant Reveal genetic test (81479) provided on 
September 10, 2023. 
 
You asked the Plan to pay for a Guardant Reveal test. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says this molecular pathology testing is not a covered 
benefit. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the DEXTM Diagnostics Exchange does not show that the 
test at issue is listed as a covered service. Based on this information, we decided that Medicare rules for 
coverage of a Guardant Reveal test have not been met. Therefore, we decided that the Plan does not have to 
pay for a Guardant Reveal genetic test (81479) provided on September 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 29, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump billed with code E0781 for May 24, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that for DMEPOS, the date of service is equal to the date 
of delivery. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct date of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the infusion pump billed with code E0781 for 
May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 15, 2023, billed with 
procedure code 00532. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate 
diagnosis code. 
 
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 the practitioner services provided have 
been met. Specifically, no medical have been provided for review. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on June 15, 2023, billed with procedure code 00532.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
(E0601) provided from July 3, 2023, to August 2, 2023. 
 
You asked the Plan to pay for a CPAP device. You say that you have billed the item at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, Medicare 
pays a monthly fee schedule amount per beneficiary. Fee schedule payments for stationary oxygen system 
rentals are all inclusive and represent a monthly allowance per beneficiary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, the item at issue has been inappropriately billed with 31 units for the rental month. Therefore, we decided that the Plan does not have to pay for a continuous 
positive airway pressure (CPAP) device (E0601) provided from July 3, 2023, to August 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on August 09, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you have a 
$0 copay for a CT scan. 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 $150 
copayment for other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $150 copayment for the computed tomography (CT) scan. This item/service falls 
within the other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays 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. However, since 
the allowed amount is less than the standard copayment, you only owe $99.93. Therefore, we decided that the 
Plan does not have to waive the copayment for the computed tomography (CT) scan provided on August 09, 
2023.