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

 
We decided that the Plan does not have to pay for procedure code 88305 for date of service February 10, 2023. 
 
You asked the Plan to pay for procedure code 88305. You say that you disagree with the Plan's denial. 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used 
when two conditions cannot occur together, such as a congenital form versus an acquired form of the same 
condition. 
 
We looked at the file and Medicare rules. Review of the file shows that code 88305 was billed with diagnosis 
codes C44.01 (Basal cell carcinoma of skin of lip) and C43.62 (Malignant melanoma of left upper limb, 
including shoulder). Due to an Excludes1 note, these two diagnosis codes should not be reported together. The 
claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88305 for date of service February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 21, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 home visit provided 
on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 06, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were provided in good faith. 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 office visit provided 
on October 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 06, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 provided on 
February 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management services provided 
on April 7, 2023, by an OON provider.  
 
You asked the Plan to pay for the telephone evaluation and management services. You say that the provider 
states they are a participating provider. The Plan denied your request. The Plan says the service was not 
authorized. 
 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 telephone evaluation and management services 
provided on April 7, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 7, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON office visit. You say that the medical records provided support that the 
services in dispute were medically necessary.  The Plan denied your request. The Plan says the services were 
provided OON without prior authorization. The Plan says that the services provided were not urgent or 
emergent in nature.  
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on July 7, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85025, 36415, 80047, 85652, and 86140 for 
date of service March 9, 2023. 
 
You asked the Plan to pay for procedure codes 85025, 36415, 80047, 85652, and 86140. 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used 
when two conditions cannot occur together, such as a congenital form versus an acquired form of the same 
condition. 
 
We looked at the file and Medicare rules. Review of the file shows that the codes at issue were billed with 
diagnosis codes T07.XXXA (Unspecified multiple injuries, initial encounter And T30.4 (Corrosion of 
unspecified body region, unspecified degree). Due to an Excludes1 note, these two diagnosis codes should not be billed together. This means this claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 85025, 36415, 80047, 85652, and 86140 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 85025, 36415, 80047, 85652, and 
86140 for date of service March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies coded as T4522 and T4525. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are appealing for the adult 
disposable products as the enrollee is incontinent relate to DeLange Syndrome The Plan denied your request. 
The Plan says this item is not covered 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies coded as 
T4522 and T4525.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transport provided on November 14, 2022. 
 
You asked the Plan to pay for the wheelchair van transport. You say that personnel at the facility scheduled a 
wheelchair transport so you could follow-up on your scheduled doctors appointment and you assumed that the 
facility personnel knew best and there was no other reasonable way to get you to your follow-up visit after 
surgery and to remove the stitches. The Plan denied your request. The Plan says ambulette services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transport provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device (L8702) to be provided by 
an out-of-network (OON) provider.  
 You asked the Plan to pre-approve the orthotic device. You say that you request reconsideration of the denial 
and permit coverage for this device. 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. This item 
is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with 
stroke and hemiparesis. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. This item is also considered experimental and investigational. 
There is insufficient evidence of its effectiveness in those with stroke and hemiparesis. Therefore, we decided 
that the Plan does not have to pre-approve the MyoPro orthotic device (L8702) to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office or other outpatient visit to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve an office or other outpatient visit to be provided by the requested out-of-
network provider You say that you have had an occipital nerve pain for over one year, every day 24/7. You say 
that you have received two nerve blocks, multiple injections, had acupuncture treatment from two separate doctors and you have taken multiple nerve medications (Lyrica, Gabapentin) that did not take the pain away. 
You say you have taken multiple physical therapy, message therapy, Botox injections, used heat and ice 
therapy, pain management, and found no one that does this nerve release surgery. The Plan denied your 
request. The Plan says your primary care physician (PCP) has certain specialists they use for referrals. This 
means the PCP you have selected may determine the specialists you use. Your PCP does not refer to the 
out-of-network provider you have requested. 
 
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 an office 
or other outpatient visit to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on January 31, 2023, billed 
with Evaluation and Management (EM) code 99223-AI. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at 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.  This claim was inappropriately billed with 
POS 21 as the enrollee was registered outpatient hospital on this date of service. Therefore, we decided that the 
Plan does not have to pay for Practitioner services provided on January 31, 2023, billed with Evaluation and 
Management (EM) code 99223-AI.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed with diagnosis codes R06.89 
and J96.02 provided from February 27, 2023, to February 28, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes R06.89 and J96.02 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 billed with diagnosis codes R06.89 and J96.02 provided from 
February 27, 2023, to February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 8, 2023, by an 
OON provider.  You asked the Plan to pay for the laboratory services. You say that the services provided should be covered. 
The Plan denied your request. The Plan says these services were not authorized. 
 
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 laboratory services provided on February 8, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TissueCypher test to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the TissueCypher test. You say that there is no in-network provider to 
perform this test. The Plan denied your request. The Plan says enrollees must get their care from network 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
TissueCypher test to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on March 7, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on March 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited appeal for the 
denial of a SNF admission. The Plan denied your request. The Plan says the SNF services requested do not 
meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, the enrollee does not require skilled therapy services on a daily basis. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81529 for date of service January 3, 2023. 
 
You asked the Plan to pay for procedure code 81529. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is missing required information. 
 
The Plan must follow Medicare rules. Medicare rules say that the claim must include the location where the 
service was rendered.  
 
 
 We looked at the file and Medicare rules. Review of the file shows that the claim did not include the location 
where the service was rendered. Based on this information, we decided that Medicare rules for coverage of 
procedure code 81529 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 81529 for date of service January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 14, 2022, to 
November 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 14, 2022, to 
November 12, 2022.