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

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing 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 the laboratory services 
provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on October 9, 2023. 
 
You asked the Plan to pay for medical supplies. You say that this is covered under your plan, you should get all 
your money back. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a $46.19 coinsurance for medical supplies. This item/service falls within the 
durable medical equipment (DME) and related 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 pay for medical supplies provided on October 9, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on  
August 14, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Masters of Social Work (MSW) are not able to be 
reimbursed by Medicare. 
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation 
provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis treatments provided on June 01, 
2023, to July 31, 2023. 
 
You asked the Plan to waive the coinsurance for dialysis treatments. You say that you cannot figure out how or 
why you are being billed so much, and at what frequency. 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 20% 
coinsurance for services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for dialysis treatments. This item/service falls within the services 
to treat kidney disease 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 $142.66 ($713.30 x 20% = $142.66). Therefore, we decided that the 
Plan does not have to waive the coinsurance for dialysis treatments provided on June 01, 2023, to July 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
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 the laboratory services rendered on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foam dressing, wound cover, sterile (A6212) and alginate 
or other fiber gelling dressing, wound cover, sterile (A6196) provided on July 27, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that this enrollee has been treated for their 
wounds and billing separately for these supplies is appropriate. 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. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 foam dressing, wound cover, sterile (A6212) 
and alginate or other fiber gelling dressing, wound cover, sterile (A6196) provided on July 27, 2023, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided on June 30, 
2023. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal testing (81479) provided on June 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve physical therapy services. 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 must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physical therapy services have been 
met. Specifically, your primary care physician states they are still working on your request and have not provided an order for services or clinical information. Therefore, we decided that the Plan does not have to pre-
approve physical therapy services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
August 20, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were told at 
check in that you did not have a copayment. Therefore, you feel you do not need to pay. 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 $90 
copayment for emergency services. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency 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 an 
emergency room (ER) visit provided on August 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87481, 87500, 87653, 87798) 
provided on April 27, 2023. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 26, 2023. Comparison of the two claims shows the claim lines denied in this case are exact duplicates of the earlier claim. There is no evidence presented to support that the billed 
items/services were provided twice on the same date. Based on this information, we decided that the Medicare 
rules for infectious-agent testing have not been met. Therefore, we decided that the Plan does not have to pay 
for infectious-agent testing (87481, 87500, 87653, 87798) provided on April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided on July 7, 
2023. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this test is not covered by Medicare. 
The Plan denied your request. The Plan says this testing was medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal testing (81479) provided on July 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36222-59-50 rendered on May 15, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 36222 will not be reimbursed. 
 
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 36222 is "Selective catheter placement, common carotid 
or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid 
circulation and all associated radiological supervision and interpretation, includes angiography of the 
cervicocerebral arch, when performed." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that CPT 36221 - 36228 is a code set 
with hierarchy. The lower-numbered codes are valued into the higher-number codes. In this case, procedure 
report does not include documentation to support separate payment for CPT 36222, and therefore the procedure 
code and modifier cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 36222-59-50 rendered on May 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic life support (BLS), non-emergency ambulance 
transport (A0428) and ground mileage (A0425) provided on August 7, 2023, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the ambulance service. You say that the enrollee had fell and due to the fact that 
one of the medicines is a blood thinner, the medical staff felt worried and sent the enrollee to the hospital to be 
looked at as a precaution.  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. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 basic life support (BLS), non-emergency 
ambulance transport (A0428) and ground mileage (A0425) provided on August 7, 2023, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
September 6, 2023, and billed with codes 87591, 87661, 87481, 87651, 87653, 87500, 87641, 87798, 87491, 
87496, 87511, 87529, 87532, G0452, and 87563. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
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 the urine polymerase chain reaction (PCR) panel provided on September 6, 2023, 
and billed with codes 87591, 87661, 87481, 87651, 87653, 87500, 87641, 87798, 87491, 87496, 87511, 87529, 
87532, G0452, and 87563.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visits provided on July 31, 2023, to August 07, 
2023. 
 
You asked the Plan to pay for chiropractic visits. You say that you saw an in-network provider, but they could 
not help you. There were payments made for the out-of-netowrk provider, so you thought they were in-network 
again. 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 visits 
provided on July 31, 2023, to August 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 05, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and 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 an office visit provided 
on September 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hand and finger orthotic provided on 
July 19, 2023. 
 
You asked the Plan to waive the coinsurance for the hand and finger orthotic. You say that the item did not 
work and kept falling off. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the hand and finger orthotic. This item/service falls within 
the durable medical equipment and related 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. The total amount you owe is $57.97 ($289.87 allowed amount x 
20% = $57.97). Therefore, we decided that the Plan does not have to waive the coinsurance for the hand and 
finger orthotic provided on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nebulizer (E0570) provided on July 15, 2023 provided on 
July 15, 2023. 
 
You asked the Plan to pay for a nebulizer (E0570) provided on July 15, 2023. You say that the Plan has made a 
clerical error. 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 nebulizer (E0570) 
provided on July 15, 2023 provided on July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01922) provided on February 8, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 01922 is not supported in the medical record. Specifically, multiple anesthesia services 
were billed on a single date of service without a required XE, XS, XP, or XU modifier. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (01922) provided on February 
8, 2023.