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

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service May 26, 
2023.  
 
You asked the Plan to pay for procedure code 88360. You say that you disagree with the denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88360 is 6. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88360 billed for date of service May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 and 87798 rendered on December 11, 
2022. 
 
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 the records do not support the services 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 the denied codes is: 
 
CPT 83520: 
 
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that codes 83520 and 87798 are not 
supported. The description for both codes indicates unlisted services. CPT rules require a report indicating 
which unlisted services were performed. The record does not specify which tests were performed and reported 
under the unlisted codes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 83520 and 87798 rendered on December 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you do not agree with the denial of the 
requested item. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87640, 87652, 87798, 87799, 
87900) provided on May 5, 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 claim cannot be paid as 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. 
 
We find that CPT codes  87481, 87500, 87640, 87652, 87798, 87799, & 87900 are not supported in the medical 
record. Specifically, multiple unbundled codes were submitted for a single panel. 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 (87481, 87500, 87640, 87652, 87798, 87799, 87900) provided on 
May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on May 23, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they are covered under your Part D benefits, not 
your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on May 23, 
2023.  
 
Benefits for the shingles vaccine 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on May 8, 2023. 
 
You asked the Plan to pay for the diagnostic radiology services. You say that radiology physicians are 
classified as silent providers. The Plan denied your request. The Plan says the Plan requires utilization of 
network providers when possible and available and requires authorization for certain services. No medical 
necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.  
 
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 diagnostic radiology services provided on May 8, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Esophagogastroduodenoscopy provided on  
April 12, 2023. 
 
You asked the Plan to pay for the Esophagogastroduodenoscopy. You say that this diagnosis is unrelated the 
hospice diagnosis nor is your provider associated with hospice. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an Esophagogastroduodenoscopy provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
February 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the Plan requires utilization of network providers when 
possible and available and requires authorization for certain services. No medical necessity for an out-of-
network provider such as an urgent or an emergent situation that has been documented.  
 
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 subsequent nursing facility care provided on February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87481, 87500, 87641, 87651, 87798, 
87801) provided on May 11, 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 claim cannot be paid as 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. 
 
We find that CPT codes 87150, 87481, 87500, 87641, 87651, 87798, & 87801 are not supported in the medical 
record. Specifically, multiple unbundled codes were billed for a single panel. 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 (87150, 87481, 87500, 87641, 87651, 87798, 87801) provided on 
May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9604 billed for date of service August 12, 
2022. 
 
You asked the Plan to pay for procedure code P9604. You say that you have billed the services 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code P9604 is: Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge. 
 
We find that CPT code P9604 is not supported. Specifically, no documentation has been provided to support a 
prorated trip charge.  Based on this information, we decided that Medicare rules for coverage of procedure code P9604 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code P9604 billed for date of 
service August 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 9, 2023, billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240- 59, 81241-59, 81291-59, 81306-59, 81328-59, 
81335-59, 81479-GY 59, and 81238- 59. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 9, 2023, billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240- 59, 81241-59, 81291-59, 
81306-59, 81328-59, 81335-59, 81479-GY 59, and 81238- 59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 2, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the home visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the home visit provided on May 2, 2023, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan; pelvis provided on March 
11, 2023. 
 
You asked the Plan to pay for computed tomography (CT) scan; pelvis. You say that you are appealing the 
claim payment denial. 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 computed tomography 
(CT) scan; pelvis provided on March 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxaliplatin, fluorouracil, leucovorin, bevacizumab-bvzr 
and pembrolizumab. 
 
You asked the Plan to pre-approve the medications. You say that this treatment represents the best chance for 
extending the enrollee's life and enhancing their quality of life. The Plan denied your request. The Plan says 
that the requested use of this drug combination is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 medications. Our reviewer says that 
that the requested drug combination is not supported. Our physician reviewer found The FDA has not stated 
that the requested drug regimen is indicated for the enrollee's specific condition. The Medicare-approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug regimen in the 
enrollee's specific clinical situation. 
 
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 medications have not been met. Therefore, we decided that the Plan does 
not have to pre-approve oxaliplatin, fluorouracil, leucovorin, bevacizumab-bvzr and pembrolizumab.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray and transportation of x-ray equipment provided 
on June 6, 2023. 
 
You asked the Plan to pay for the chest x-ray and transportation of x-ray equipment. The Plan denied your 
request. The Plan says the enrollee must use network providers to get medical care and services. The only 
exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis 
services, and cases in which our Plan authorizes use of out-of-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 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 a chest x-ray and transportation of x-ray equipment provided on 
June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care provided on 
January 6, 2023, and January 7, 2023.  
 
You asked the Plan to pay for the subsequent hospital inpatient or observation care. You say that the services 
were medically necessary. The Plan denied your request. The Plan says 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 subsequent hospital inpatient or observation care provided on 
January 6, 2023, and January 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on February 17, 2023, and  
April 15, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that this provider was recommended to you by a 
friend. The Plan denied your request. The Plan says that the Plans contracted provider is the only non-clinic 
system telehealth provider covered by this Plan. If you use another non-clinic system telehealth provider, you 
will be responsible for all charges. 
 
The Plan must contract says that the Plans contracted provider is the only non-clinic system telehealth 
provider covered by this Plan. If you use another non-clinic system telehealth provider, you will be responsible 
for all charges. 
 
We looked at the file and the Plans rules. The file shows that you did not use that the Plans contracted 
provider for telehealth services. Based on this information, we decided that the Plans rules for coverage of the 
telehealth services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth 
services provided on February 17, 2023, and April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on April 
03, 2023. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that you should only have a 
$15 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 a specialist office visit provided on April 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider.  
 
You asked the Plan to pre-approve the physician's services. You say that you have been seeing this doctor for 
years for osteoporosis, auto immune disease, arthritis as well as multiple injections but due to a hospitalization 
you are now on different medications prescribed by this doctor, and you were seeing this doctor weekly while 
on the Plan so you do not know why it would be an issue now. The Plan denied your request. The Plan says this 
doctor is not in-network. There needs to be a medical reason you need to see a doctor who is out-of-network as 
there are in-network doctors that you can see. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
physician's services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
March 28, 2023, to April 25, 2023. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you are on a limited 
income and need assistance with these bills. 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 $45 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $45 copayment for each specialist office visit. This item/service falls within the 
specialist physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for each specialist office visit provided on March 28, 2023, to April 25, 2023.