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

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 17, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a covered service and this claim 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1 . The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on September 7, 2022, and September 8, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visits. You say that you are allowed to receive care from an out-of-
network provider. The Plan denied your request. The Plan says that you must receive your care from a network 
provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a complete copy of the correct Evidence of Coverage 
(EOC). Therefore, we decided that the Plan has to pay for the office visit provided on September 7, 2022, and 
September 8, 2022, by an out-of-network (OON) provider.   
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from August 29, 2022, to September 20, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this is a medical necessity 
appeal based on medical literature and the efficacy of the treatment rendered. The Plan denied your request. 
The Plan says this service does not meet the requirement of the enrollee's plan of benefits and is excluded from 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided from August 29, 2022, to 
September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on September 7, 
2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC molecular diagnostic test (0315U) 
provided November 18, 2022. 
 You asked the Plan to pay for the laboratory service You say that the test was ordered by the treating physician 
with the intent to use the DecisionDX-SCC test results to inform treatment decisions. The Plan denied your 
request. The Plan says this is not a Medicare approved study and is 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 the file and Medicare rules. The Diagnostic Exchange (DEX) Registry indicates the test is not 
covered under MolDX Program, not supported by FDA. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDx-SCC molecular diagnostic test (0315U) provided November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full face mask used with positive airway pressure device 
(A7030), replacement face mask interface (A7031), headgear used with positive airway pressure device 
(A7035), and water chamber for humidifier (A7046) provided on May 11, 2022 to November 15, 2022, by an 
out-of-network (OON) provider.  
 You asked the Plan to pay for the full face mask, replacement face mask interface, headgear, and water 
chamber for humidifier. You say that you have been contracted with the Plan since 2013. You also say that you 
would like the Plan's records to be verified and for this claim to be reprocessed. The Plan denied your request. 
The Plan says the replacement CPAP and supplies were supplies by an OON 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 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 full face mask used with positive airway 
pressure device (A7030), replacement face mask interface (A7031), headgear used with positive airway 
pressure device (A7035), and water chamber for humidifier (A7046) provided on May 11, 2022 to November 
15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 34713 billed for date of service October 21, 
2022.  
 You asked the Plan to pay for procedure code 34713. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 34713 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 34713 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 34713 billed for date of service October 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 10, 2023, to 
January 30, 2023, by an out-of-network provider.  
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says the provider is 
non-participating with the Plan, and not Medicare qualified.  
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. 
 
Medicare rules say that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
 
The requested provider in this case is not a network provider with the Plan. The provider at issue in this case is 
a Marriage Family Therapist. Medicare says that a Marriage Family Therapist is not eligible to participate in 
the Medicare program. The Plan did not pre-approve the services at issue. We found no exception that would 
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided from January 10, 2023, to January 30, 2023, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 6, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. 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 Plan says that the Plan has 
also determined that these services are 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has 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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is not imaging that clearly shows the cause of the enrollee's pain. There are 
multiple possible causes of the enrollee's pain. Without additional information, this procedure is not supported. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower tub. 
 
You asked the Plan to pre-approve a walk-in shower tub. The Plan denied your request. The Plan says a walk-
in shower tub is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower tub.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 20, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a covered service and this claim 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 168 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 168 routine transportation trips. You say that you need 
transportation for medical appointments. The Plan denied your request. The Plan says this request will exceed 
the maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 168 routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675) provided October 
10, 222 to October 31, 2022. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that the Plan has coverage for DME 
and the charges are medically necessary, therefore all charges should b paid in full. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  a pneumatic compression device (E0675) provided October 10, 222 to October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (81455) provided 
on March 24, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for genetic testing. You say that molecular testing was requested directly from the 
treating physician who makes the professional determination of diagnosis and medical necessity to successfully 
treat the enrollee. 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 targeted genomic sequence analysis panel (81455) 
provided on March 24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 28, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on December 
14, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. 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 molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
October 22, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that FoundationOne CDx was ordered by the 
treating physician because the test results were needed to help determine the course of treatment. The Plan 
denied your request. The Plan says the documentation does not support the date of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of code 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the records show a 
collection date of February 1, 2022, a received date of October 13, 2022, and a report date of October 22, 2022. 
The date of service billed is October 22, 2022. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the FoundationOne CDx (F1CDx) test (0037U) provided October 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the mental health care office visit provided 
on February 16, 2023. 
 
You asked the Plan to reduce the copayment for the mental health care office visit. You say that you should 
only have a $35 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 $85 
copayment for in-network outpatient mental health care provided at an outpatient hospital. 
 
You have been asked to pay a $85 copayment for the mental health care office visit. This item/service falls 
within the in-network outpatient mental health care provided at an outpatient hospital 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. The records show the 
services were provided at an outpatient hospital, and the copayment was applied correctly. Therefore, we 
decided that the Plan does not have to reduce the copayment for the mental health care office visit provided on 
February 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service October 26, 
2022 to November 1, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service October 26, 2022 to November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heating pad with pump (E0217) 
provided from September 15, 2022, to October 4, 2022. 
 
You asked the Plan to pay for the heating pad. You say that the enrollee's medical necessity actually meets the 
guidelines that qualify for coverage. The Plan denied your request. The Plan says this item is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the heating pad have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heating pad with pump (E0217) provided from September 15, 2022, to October 4, 2022.