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

 
We decided that the Plan does not have to pay for lab services (87502, 87634) provided on July 20, 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 billed codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87502, 87634) provided on July 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from January 18, 2022, to 
February 16, 2022. 
 You asked the Plan to pay for home health care. You say that you are appealing this denial. 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 January 18, 2022. The NOA was not received by the Plan until December 
7, 2022. As more than 30 days passed between 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 home health care provided 
from January 18, 2022, to February 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
10, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are unable to make a 
payment. 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 $245 
copayment for ambulance services. 
 
You have been asked to pay a $245 copayment for the ambulance services. This item/service falls within the 
ambulance 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 the ambulance 
services provided on March 10, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a High Frequency Chest Wall Oscillation (HFCWO) 
system (E0483). 
 
You asked the Plan to pre-approve a HFCWO system. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that HFCWO (E0483) are covered for beneficiaries who 
meet specific criteria. 
 
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 HFCWO system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a high-frequency chest wall 
oscillation device is not medically necessary. This enrollee has a diagnosis of chronic obstructive pulmonary 
disease (COPD) and a chronic productive cough. There is no diagnosis of bronchiectasis, cystic fibrosis or 
neuromuscular disease. Medicare does not cover the high-frequency chest wall oscillation device in the 
treatment of COPD because it has not been shown to be beneficial for this condition. 
 
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 HFCWO system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a High Frequency Chest Wall Oscillation (HFCWO) system (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services described by code 
99495 billed for June 29, 2023. 
 
You asked the Plan to pay for 99495. You say that 99495 should be paid as billed because it was coded 
correctly, and this service was not billed for this enrollee more than once within a 30-day period. The Plan 
denied your request. The Plan says 99495 is denied because records do not contain documentation of 
communication with the enrollee and/or caregiver within 2 business days of their discharge date. 
 
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 99495 is transitional care management services with the 
following required elements: communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge, at least a moderate level of medical decision making during the service period, and a face-to-face visit, within 14 calendar days of discharge. 
 
We find that CPT code 99495 is not supported in the medical record. Records indicate the enrollee was 
discharged from the hospital on June 25, 2023. We confirmed that the case file does not contain documentation 
or evidence of communication (direct contact, telephone, or electronic) with the enrollee and/or caregiver 
within 2 business days of their discharge from the hospital, as required for reporting code 99495. Based on this 
information, we decided that Medicare rules for coverage of 99495 have not been met. Therefore, we decided 
that the Plan does not have to pay for the transitional care management services described by code 99495 billed 
for June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 23, 
2023, to June 13, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says Claims for 
E0675 will be denied as not reasonable and necessary. 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. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Also, the requested provider in this case is not a 
network provider with the Plan. The Plan did not pre-approve the item/service at issue.  Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 23, 2023, to June 
13, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid-circulating cold pad with pump (E0218) provided 
from May 24, 2023, to June 12, 2023. 
 
You asked the Plan to pay for a fluid-circulating cold pad with pump. You say that the item at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the item at issue is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid-circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of a fluid-circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid-circulating cold pad with pump (E0218) provided from May 24, 2023, to June 12, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 73502 provided on August 17, 
2023. 
 
You asked the Plan to pay for procedure codes 93005 and 73502. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the billed codes are not separately 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 CPT code 93005 and 73502 is not supported in the medical record. Specifically, codes  93005 and 
73502 have a status indicator of Q1 and were billed on the same date of service as code 99285 which has a 
status indicator of "V". These codes are packaged with code 99285 and are not separately payable. Based on 
this information, we decided that Medicare rules for coverage of procedure codes 93005 and 73502 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93005 and 73502 
provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on January 13, 
2023, to February 08, 2023. 
 
You asked the Plan to waive the copayment for each office visit. You say that you want to appeal the amount 
being charged. 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 each 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. The total you owe is $75 ($25 copayment x 3 visits 
= $75). Therefore, we decided that the Plan does not have to waive the copayment for each office visit provided 
on January 13, 2023, to February 08, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 17, 2023 to 
February 2, 2023. 
 You asked the Plan to pay for home health services. You say that the claim was submitted timely. 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 January 17, 2023. The NOA was not received by the Plan until June 13, 
2023. As more than 30 days passed between 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 home health services provided 
from January 17, 2023 to February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on July 13, 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 July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCA 1/2 Panel (81432, 81433) provided on August 10, 
2023. 
 
You asked the Plan to pay for the BRCA 1/2 Panel. You say that this test was medically necessary as the 
enrollee has family history of cancer. The Plan denied your request. The Plan says this test would be 
considered a screening, as the enrollee has no personal history of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the BRCA 1/2 Panel, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes (i.e., an enrollee with no personal history of cancer). 
Therefore, we decided that the Plan does not have to pay for the BRCA 1/2 Panel (81432, 81433) provided on 
August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 30, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 the laboratory services 
provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital observation provided 
on August 18, 2023, to August 19, 2023. 
 
You asked the Plan to waive the copayment for an outpatient hospital observation. You say that you did not 
know there was a copayment for this service - if you had known you would have asked to be discharged. 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 $350 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $350 copayment for an outpatient hospital observation. This item/service falls 
within the outpatient hospital observation 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 hospital observation provided on August 18, 2023, to August 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 21, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for covid testing provided on July 11, 2023, to July 14, 2023. 
 
You asked the Plan to pay for covid testing. You say that you want his test paid for, it 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 covid testing provided 
on July 11, 2023, to July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on August 01, 
2023, to August 14, 2023. 
 
You asked the Plan to pay for evaluation and management services. You say that you are requesting 
reconsideration for 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 evaluation and 
management services provided on August 01, 2023, to August 14, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot be safely discharged home. You require 
a few more weeks of SNF care. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF 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 a continuation of SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on August 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for podiatry services. You say that you were not aware that prior authorization was 
needed. The Plan denied your request. The Plan says that their original decision to deny payment was correct. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 podiatry services provided on August 17, 2023, by 
an OON provider.