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

 
We decided that the Plan does not have to pay for procedure codes 22551, 22552, 22846, and 22853, billed for 
date of service August 3, 2023.  
 
You asked the Plan to pay for procedure codes 22551, 22552, 22846, and 22853. The Plan denied your request. 
The Plan says the claim is not payable as billed. 
 
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 22551 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 codes 22551 have not been met. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that codes 22552, 22846, and 22853, are add-on codes 
and have not been billed with an appropriate primary procedure code. 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 codes 22551, 22552, 22846, and 22853, 
billed for date of service August 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
September 13, 2023, to September 16, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told the stay 
would be fully covered. 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 $325 
copayment for inpatient hospital care. 
 
You have been asked to pay a $325 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital 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. You have been asked to pay a total of $975 for the inpatient hospital stay ($325 copayment 
x 3 days = $975). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on September 13, 2023, to 
September 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22513). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 kyphoplasty. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of a trial and failure of fracture bracing. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty procedure (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service March 20, 
2023, to April 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was treated for post-surgical 
lymphedema. The Plan denied your request. The Plan says the device does not meet the requirements for 
approval. 
 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 E0675 is not supported in the medical record. Code E0675 is used for the treatment of 
peripheral arterial disease. The records show that a pneumatic compression device was used for the treatment 
of lymphedema. 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 procedure code E0675 billed 
for dates of service March 20, 2023, to April 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity.  
 You asked the Plan to pre-approve Evenity. You say that the drug is medically necessary for treatment. The 
Plan denied your request. The Plan says there is no contraindication or intolerance to the preferred agents 
Forteo. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found there is no documentation provided indicating 
that the plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 12, 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 July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87641 billed for date of service April 7, 
2023. 
 You asked the Plan to pay for procedure code 87641. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 87641 is bundled into payment for code 87801. 
 
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 87641 
is a column II code to column I code 87801. 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 87641 billed for date of service April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on August 29, 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 29, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, 99232, and 99233 billed for dates of 
service June 13, 2023, to June 20, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 13, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for procedure codes 99223, 
99232, and 99233 billed for dates of service June 13, 2023, to June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray billed with code 73130 for August 4, 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 services are 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 has an OPPS status indicator of Q1(S) 
and was billed with code 99284, which has an OPPS status indicator of V. Code 73130 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 x-ray billed with code 73130 for August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 22, 2023, billed 
with procedure code 81479. 
 
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 August 22, 2023, billed with procedure code 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails provided on July 06, 2023. 
 
You asked the Plan to pay for debridement of nails. 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 debridement of nails 
provided on July 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing procedures (81407, 81408, 
81479) billed for date of service January 11, 2023. 
 
You asked the Plan to pay for molecular pathology testing procedures. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the services at issue were incorrectly 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for molecular pathology testing procedures. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the provided records in this case document a 108-Gene Panel (Primary 
Immunodeficiency Focus) was collected on January 11, 2023, with a report date of February 13, 2023, from a 
saliva swab. The specimen was analyzed for multiple gene variants. The provided records do not fully clarify 
that all of the genes analyzed by the Primary Immunodeficiency Focus are the genes cited in CPT codes 81407, 
81408 and 81479. The provided records do not clarify what genes were tested under code 81479. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular pathology testing procedures have not been met. Therefore, we 
decided that the Plan does not have to pay for molecular pathology testing procedures (81407, 81408, 81479) 
billed for date of service January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on June 14, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you did not obtain a referral, but this was medically 
necessary for this enrollee, which is why you attached medical records along with this appeal. 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 outpatient office visit (99203) provided on 
June 14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses (V2781 x2) provided on June 2, 2023, 
with an out-of-network provider.  
You asked the Plan to pay for the progressive lenses. You say that the services should be covered. The Plan 
denied your request. The Plan says you purchased progressive lenses from an out-of-network provider without 
prior authorization. These items are available in-network. 
 
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. The Plan covers these services when you utilize an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay 
for the progressive lenses (V2781 x2) provided on June 2, 2023, with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the insertion or replacement of permanent 
implantable defibrillator system provided on July 26, 2023. 
 
You asked the Plan to waive the cost share for the outpatient surgery. You say that you met your out-of-pocket 
maximum and should not be responsible for this copayment amount. 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 have an in-
network maximum out-of-pocket amount of $6,700. Also, the contract says that enrollees must pay in-network 20% of the cost for each Medicare-covered visit to an outpatient hospital facility, certified ambulatory surgical 
center, or clinic. Authorization rules may apply. 
 
You have been asked to pay a $4,517.89 to meet your maximum-out-of-pocket of $6700 for the outpatient 
surgery. This item/service falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. You had not met your maximum out-of-pocket prior 
to date of service July 26, 2023. 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 the insertion or replacement 
of permanent implantable defibrillator system provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 and 88313 billed for date of service 
February 20, 2023. 
 You asked the Plan to pay for procedure code(s) 88305 and 88313. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305 and 88313. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305 and 
88313. Based on this information, we decided that Medicare rules for coverage of procedure code 88305 and 
88313 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88305 and 88313 billed for date of service February 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the methadone treatment provided on January 12, 2023, to 
June 01, 2023. 
 
You asked the Plan to pay for the methadone treatment. You say that you are asking for the review of the 
medical 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 the methadone treatment 
provided on January 12, 2023, to June 01, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 9, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 9, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay 
provided on April 01, 2023, to April 11, 2023. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) stay. You say that you did 
were not told you were over your 20 days, so you should not have to pay the billed amount. 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 $196 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $196 copayment for the skilled nursing facility (SNF) stay. This item/service falls within the skilled nursing facility (SNF) 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. You have been asked to pay a total of $196 for the SNF stay 
($196 copayment x 1 day = $196). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay provided 
on April 01, 2023, to April 11, 2023.