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

 
We decided that the Plan does not have to pay for a home visit evaluation provided on August 08, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on August 08, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room stay and self-administered drugs 
provided from July 31, 2023, to August 2, 2023. 
 
You asked the Plan to pay for emergency room stay and self-administered drugs. You say that  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 $110 
copayment for emergency room stay.  
 
You have been asked to pay $110 copayment for emergency room stay. This item/service falls within the 
Emergency Care 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. Additionally, the self-administered drugs you received are not covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pay for an emergency room stay and self-administered 
drugs provided from July 31, 2023, to August 2, 2023.  
 
Benefits for emergency room stay and self-administered drugs may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmented pneumatic compression device (PCD) with arm 
and trunk attachments coded as E0652, E0668, and E0656 to be furnished by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the OON PCD and related supplies. You say that the enrollee has lymphedema 
due to mastectomy and requires this specific PCD from the OON provider. There is no comparable device 
available that can meet her needs. The Plan denied your request. The Plan says there are various network 
suppliers who can provide the same type of device of a different brand. As there is no network deficiency, the 
denial of OON coverage is correct.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. Though it is noted that there are no 
comparable devices, there are many brands that have been assigned the same code. No objective differences are 
described to support that none of these other brands are suitable for the enrollee. 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 a segmented pneumatic compression device (PCD) with arm and trunk attachments coded as E0652, E0668, 
and E0656 to be furnished by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail fungal infection polymerase chain reaction (PCR) 
panel provided on September 15, 2023. 
 
You asked the Plan to pay for the nail fungal infection PCR panel. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the nail fungal infection polymerase chain reaction (PCR) panel provided on 
September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 3, 2023, billed with 
procedure code G0318. 
 
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 documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
In this case, the CPT/HCPCS Code Manual definition of code G0318 is prolonged home or residence 
evaluation and management service(s) beyond the total time for the primary service (when the primary service 
has been selected using time on the date of the primary service); each additional 15 minutes by the physician or 
qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 
99345, 99350 for home or residence evaluation and management services). (Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (Do not 
report G0318 for any time unit less than 15 minutes). 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that G0318 represents a timed code, in this 
case documentation of time as well as prolonged evaluation and management service was not included in 
procedure report. Therefore, procedure code cannot be verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 3, 2023, billed with procedure code 
G0318.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Orthosis. 
 
You asked the Plan to pre-approve a MyoPro Orthosis. You say that you need this to be able to use your left 
arm again. The Plan denied your request. The Plan says this is experimental. 
 
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 MyoPro Orthosis. Our reviewer says 
that the requested a MyoPro Orthosis is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective in improving health outcomes 
based on scientific evidence, professional standards, and expert opinion. There is insufficient evidence in the 
literature that the MyoPro Orthosis will improve your long term outcome. 
 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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 24, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the services. You say that you were not aware that you were out-of-network. The 
Plan denied your request. The Plan says prior authorization was not received in time. 
 
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 services provided on May 24, 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 optometry services provided on November 21, 2022, by an 
out-of-network (OON) provider.  
 
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 there were network providers available. 
 
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 optometry services provided on November 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing billed with 
codes 87150, 87798, 87481, 87840, and 87653 provided on September 8, 2023. 
 
You asked the Plan to pay for the urine PCR testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) testing billed with codes 87150, 
87798, 87481, 87840, and 87653 provided on September 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81226) provided on March 23, 2023. 
 
You asked the Plan to pay for 81266. You say that this test is a covered benefit. The Plan denied your request. 
The Plan says this code is 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 code 81226 is CYP2D6 (cytochrome P450, family 2, 
subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, 
*10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN). 
 
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 81266. Our reviewer says that this code is not supported for 
payment. Our reviewer found the documentation describes 20 genes tested so a more appropriate code should be reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 81266 have not been met. Therefore, we decided that the Plan does not have to 
pay for genetic testing (81226) provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4208, 96375, 96374, and A4649, billed for 
date of service May 28, 2023.  
 
You asked the Plan to pay for procedure codes A4208, 96375, 96374, and A4649. The Plan denied your 
request. The Plan says the services are not payable. 
 
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 A4208 is 0. The MAI value for this code is 2. You billed 1 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code have not been met. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate procedure code. 
 
We find that procedure code 96375 and 96374 are assigned PC/TC indicator 5. This indicator identifies codes 
that describe services covered incident to a physician's service when they are provided by auxiliary personnel 
employed by the physician and working under his or her direct personal supervision. These services are not 
payable when they are provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 
26 and TC cannot be used with these codes. As the claim was billed with an outpatient place of service, codes 
96375 and 96374 are not payable in this case. We also find that code A4649 has a status indicator of P on the 
Physician Fee Schedule. This means that procedure code A4649 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of procedure code A4649 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes A4208, 96375, 96374, and 
A4649, billed for date of service May 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries.  
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that the patient needs 
reassessment due to carotid disease and coronary artery disease (CAD). The Plan denied your request. The Plan 
says the requested duplex scan of extracranial arteries 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 pre-approve a duplex scan of extracranial arteries. 
Our reviewer says that the requested duplex scan of extracranial arteries is not considered medically reasonable 
and necessary in this case. Our physician reviewer found this patient with no change in symptoms or physical 
exam since the previous study. Guidelines do not support a need for repeat carotid duplex scan extracranial 
bilateral study (93880). As a result, at this time cardiac doppler imaging would not be considered medically appropriate and necessary in this patient's clinical management. 
 
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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 2, 2023.  
 
You asked the Plan to pay for procedure code 99497. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 
99223. 
 
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 99497 is a column two code to column one code 99223 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 99497 billed for date of service July 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer provided on July 11, 2023. 
 
You asked the Plan to pay for adjacent tissue transfer. You say that the services should be covered. 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 adjacent tissue transfer 
provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code 99244. 
 
You asked the Plan to pre-approve procedure code 99244. You say that the services are medically necessary. 
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 99244 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99244 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99244 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code 99244.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
11, 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 September 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs, 
diagnostic radiology and an outpatient diagnostic test provided on May 10, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs, diagnostic radiology and an 
outpatient diagnostic test. You say that you disagree with the cost share. 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 Medicare Part B prescription drugs, a $175 copayment for outpatient diagnostic tests/diagnostic radiology and a $5 copayment for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs, a $175 copayment for 
diagnostic radiology and a $5 copayment for an outpatient diagnostic test. The total allowed amount for the 
prescription drugs is $2,285.30, you are being asking to pay $457.06 ($2,285.30 x 20% = $457.06). The total 
amount you are being asked to pay is $637.06 ($457.06 + $175 + $5 = $637.06). This item/service falls within 
the Medicare Part B prescription drugs and outpatient diagnostic tests/diagnostic radiology/other outpatient 
diagnostic tests 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 cost share for Medicare Part B 
prescription drugs, diagnostic radiology and an outpatient diagnostic test provided on May 10, 2023.