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

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service January 10, 
2023. 
 
You asked the Plan to pay for procedure code 36556. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the payment for this service is included in 
the payment for code 47600, which was provided on January 3, 2023, and has a global surgery period of 90 
days. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a postoperative period of 90 days applies to major surgeries. The payment for the surgical 
procedure includes payment for all related care provided during the postoperative period. Modifiers 79 and 24 
are used to report services performed by the same physician which are unrelated to the initial procedure and 
therefore require separate payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36556 have not been met. Specifically, this service was performed by the same 
physician within the 90-day global surgery period of another procedure. This service was not billed with a 
necessary modifier to indicate that it is not related to and therefore not included in the payment for the previous 
procedure. Therefore, we decided that the Plan does not have to pay for procedure code 36556 billed for date of 
service January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Hereditary Cancer Syndrome panel testing coded as 
81162, 81433, 81435, 81436, 81437 and 81438.  
 
You asked the Plan to pre-approve the genetic testing. You say that please see pathology, labs and office notes 
for authorization. The Plan denied your request. The Plan says under Medicare rules the service is not 
medically necessary. Procedure codes 81438, 81433 are not covered codes and procedure codes 81433 and 
81162 duplicate genes tested under 81432. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have family history of breast cancer and has a sister with colon 
cancer. The enrollee was diagnosed with Stage 1A right breast cancer in January 2023. Oncotype testing 
showed a score of 36 (high risk of recurrence).  Agree with the decision to cover just the CPT 81432 - genomic 
sequence analysis panel for cancers of the breast, uterus, and ovaries given the high oncotype score.  
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Hereditary Cancer Syndrome panel testing coded as 81162, 81433, 81435, 81436, 
81437 and 81438.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 9, 2023, by an OON
provider.

You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied
claim. The Plan denied your request. The Plan says this 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 Plan contract says the enrollee's POS benefit only applies to
covered routine dental services.

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 office visit provided on March 9, 2023, by an OON
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A9270) provided from February 20, 2023, to 
February 22, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
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 payment for CPT code A9270 is not supported in the medical record. Specifically, code A9270 is 
not payable when billed on an outpatient claim. 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 the 
services (A9270) provided from February 20, 2023, to February 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 27, 2023, to 
February 22, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be reprocessed 
because the NOA was submitted on December 29, 2022. The Plan denied your request. The Plan says the NOA 
was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 28, 2022. The NOA was not received by the Plan until April 27, 
2023. As more than 30 days passed since the timely filing date and the NOA receipt, no payment can be made 
on this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from January 27, 2023, to February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
October 23, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. The Plan denied your request. The Plan says 
payment for codes 87481 and 87653 are 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.  
 
The file shows that a urinary tract infection panel test was provided. In this case, we have confirmed that codes 
87481 and 87653 is a column II code to column I code 87801. The codes at issue were billed with an XU 
modifier. The records do not show that the codes were a separate and distinct service. 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 87481 and 87653 billed for date of service October 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 30, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services were provided due to high 
need. 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 March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker, folding, wheeled, adjustable or fixed height 
(E0143) and a seat attachment (E0156) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a walker and a seat attachment. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the enrollee must use these network 
providers for most services, except for emergency services and routine travel dialysis. The service or items 
requested may be obtained from an in-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 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. Therefore, we decided that the Plan does not have to pre-approve 
a walker, folding, wheeled, adjustable or fixed height (E0143) and a seat attachment (E0156) 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 pay for the home visit provided on January 07, 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 January 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's care can be provided in the current 
inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee continues to get weaker every day and a 
lower level of care is not enough to adequately help return to the prior level of care and improve quality of life. 
The Plan denied your request. The Plan says the enrollee's medical condition requires further evaluation and 
treatment in the acute care hospital and must be able to participate in and benefit from intensive rehabilitation 
therapy. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 21, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you were sent samples by a provider. 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 March 21, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
December 09, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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 $250 
copayment for outpatient surgery. 
 
You have been asked to pay a $250 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 an outpatient surgery 
provided on December 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service March 29, 
2023.   
You asked the Plan to pay for procedure code 99458. You say that you disagree with the Plan's 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 99458 is 3. The MAI value for this code is 3. You billed 5 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 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service March 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on January 6, 
2023. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
were reported correctly. The Plan denied your request. The Plan says this claim was submitted without a valid 
place of service code. A corrected claim is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Although the provider states that this claim was submitted with place 
of service (POS) code 41, the claim forms show a POS of "XX". This is not a valid POS code recognized by 
Medicare. This claim should be resubmitted with the POS code entered. Based on this information, we decided 
that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services (A0427, A0425) provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network office visit provided on 
February 01, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network office visit. You say that you disagree with 
the coinsurance. 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 30% 
coinsurance for out-of-network physician/practitioner services/specialist. 
 
You have been asked to pay 30% coinsurance for an out-of-network office visit. This item/service falls within 
the out-of-network physician/practitioner services/specialist benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total allowed amount for the office visit is 
$133.80. You are being asked to pay $40.14 ($133.80 x 20% = $40.14). Therefore, we decided that the Plan 
does not have to waive the coinsurance for an out-of-network office visit provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on June 17, 2022. 
 
You asked the Plan to pay for telehealth services. You say that you are requesting a reconsideration of the 
denied charges. 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 telehealth services 
provided on June 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve Minuteman. You say that the Plan's denial is inconsistent with accepted 
medical practice. The Plan denied your request. The Plan says the efficacy of this procedure has not been 
established. 
 
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 Minuteman. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman fusion plate is intended for use with bone graft material and not for standalone 
use. In addition, there are multiple alternative pain generators possibly contributing to the enrollee's clinical 
condition that have not been fully documented as being excluded or ruled out. There is no compelling rationale or extenuating circumstance noted to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Minuteman have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgery services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the surgery services. You say that the procedure is medically necessary. The 
Plan denied your request. The Plan says this service is not approved. 
 
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 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 the surgery services. Therefore, we decided that the Plan 
does not have to pre-approve the surgery services to be provided by an OON provider.