Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided on May 9, 2023. 
 
You asked the Plan to pay for procedure codes 96365 and 96366. 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.  
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. 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 codes 96365 and 96366 provided 
on May 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological services and an office visit provided on 
August 30, 2022. 
 
You asked the Plan to pay for the radiological services and an office visit. 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 radiological services 
and an office visit provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit, and a periodic comprehensive 
preventive medicine reevaluation provided on April 13, 2023. 
 
You asked the Plan to pay for an annual wellness visit, and a periodic comprehensive preventive medicine 
reevaluation. You say that you think that this provider is in-network. 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 an annual wellness visit, 
and a periodic comprehensive preventive medicine reevaluation provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (98941, 97014, 99203) provided on 
January 24, 2023, to February 07, 2023. 
 
You asked the Plan to pay for chiropractic services (98941, 97014, 99203). You say that the provider would not 
fill out a pre-authorization. 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 chiropractic services 
(98941, 97014, 99203) provided on January 24, 2023, to February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001x25).

You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the requested treatment is medically necessary. The Plan denied your request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed or effective for the enrollee's skin cancer.

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 ultrasound guided radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found usually, image-guided radiotherapy (IGRT) is used when critical structures are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has not been established by published data or supported by consensus guidelines (many of which recommend against treatment with these devices in general) is not necessary. The decision is unfavorable as billing for daily IGRT which would not be "furnished in accordance with accepted standards of medical practice".

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001x25).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 15, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services rendered were 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 a home visit provided on 
May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 20, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory work provided on May 04, 2023. 
 
You asked the Plan to waive the copayment for laboratory work. You say that this should be covered in full, 
you have not had to pay a copay for this in the past. 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 $5 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $5 copayment for laboratory work. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 laboratory work provided on May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network dermatology visit provided 
on May 12, 2023. 
 
You asked the Plan to waive the copayment for an in-network dermatology visit. You say that you did not have 
anything removed this day, you only had a skin check. 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 $35 
copayment for a Specialist office visit. 
 
You have been asked to pay a $35 copayment for an in-network dermatology visit. This item/service falls 
within the a Specialist office visit 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 in-network dermatology visit provided on May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on March 09, 2023. 
 
You asked the Plan to pay for nursing facility care.. You say that you have an exclusive contract with the 
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 nursing facility care. 
provided on March 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive audiometry evaluation, and related 
services provided on December 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive audiometry evaluation, and related services. You say that the 
provider is in-network. 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 items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 comprehensive audiometry evaluation, and 
related services provided on December 15, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dual-energy X-ray absorptiometry 
(DXA),diagnosticmammography and an ultrasound provided on April 17, 2023. 
 
You asked the Plan to pay for dual-energy X-ray absorptiometry (DXA),diagnosticmammography and an 
ultrasound. You say that the services should be covered. 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 dual-energy X-ray 
absorptiometry (DXA),diagnosticmammography and an ultrasound provided on April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 18, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are appealing the denial with supporting 
documentation. 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 
April 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 6 units of initial nursing facility care (99305) provided from 
February 15, 2023, to February 20, 2023. 
 
You asked the Plan to pay for 6 units of initial nursing facility care. You say that these services are supported 
in the records. The Plan denied your request. The Plan says these services were not billed correctly. 
 
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 99305 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 35 minutes must be met or exceeded. 
 
We find that 6 units of CPT code 99305 is not supported in the medical record. Specifically, the records 
document subsequent rather than initial care. Based on this information, we decided that Medicare rules for 
coverage of 6 units of initial nursing facility care have not been met. Therefore, we decided that the Plan does 
not have to pay for 6 units of initial nursing facility care (99305) provided from February 15, 2023, to February 
20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the elevation system is 
medically necessary because the enrollee needs assistance getting in and out of vehicles. You also say that two 
of the enrollee's representatives have pick-up trucks. The Plan denied your request. The Plan says Medicare 
guidance excludes this service from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network telehealth visit provided on 
March 24, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network telehealth visit. You say that you do not believe 
this was an actual visit, and so you should not have to pay this 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 a 
maximum $900 coinsurance for doctor and other health care provider services.  
 
You have been asked to pay a $99.42 coinsurance for an in-network telehealth visit. This item/service falls 
within the doctor and other health care provider 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 coinsurance for an in-network telehealth visit provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 6, 2023, billed with 
procedure codes 87631, 87641, 87500, and 87998. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support codes 87641, 
87500 and 87798. Code 87631 denied for exceeding maximum units allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also 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 CPT Code Manual definition of codes 87631, 87641, 87500, and 87798 is infectious agent 
detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, 
metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse 
transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 
targets, infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique, infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance 
(eg, enterococcus species van A, van B), amplified probe technique, and 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that documentation does not support 
codes 87641 and 87500.  Medical record does not include documentation of procedure reported with CPT 
87798 and therefore cannot be verified.  
 
In this case, the MUE for CPT code 87631 is 1. The MAI value for this code is 3. You billed 2 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. 
 
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 practitioner services provided have not been met.  Therefore, we decided 
that the Plan does not have to pay for practitioner services provided on January 6, 2023, billed with procedure 
codes 87631, 87641, 87500, and 87998.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87798, 87529, 87625, and 87591 
billed for date of service March 15, 2023. 
 
You asked the Plan to pay for the billed services. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
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 panel testing was provided. The records do not show that the individual genes, billed by 
codes 87491, 87798, 87529, 87625, and 87591 were specifically requested by the provider. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87491, 87798, 87529, 87625, and 87591 
billed for date of service March 15, 2023.