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

 
We decided that the Plan does not have to pay for a mammography provided on August 10, 2023. 
 
You asked the Plan to pay for a mammography. You say that the services 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 mammography 
provided on August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service August 3, 
2023. 
 
You asked the Plan to pay for procedure code 0245U. You say that medical records were provided. The Plan 
denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 
 
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 ThyGeNEXT with Reflex to ThyraMIR test was provide. In this case, we have confirmed 
that code 0245U is a column II code to column I code 0018U. Code 0245U was billed with the -59 modifier. 
The records do not show that code separate and distinct procedures were provided for the test at issue. 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 0245U billed for date of service August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and electrocardiogram (ECG) services 
provided on October 27, 2023, by an out-of-network (OON) provider.  
 
 
 You asked the Plan to pay for the office visit and ECG services. You say that the supporting documentation 
provided should be reviewed and ask for the decision to be reconsidered. The Plan denied your request. The 
Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and electrocardiogram (ECG) 
services provided on October 27, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an electric wheelchair purchased on October 1, 
2023, from an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for a wheelchair. You say that in order to remain ambulatory and to lessen 
pain, you purchased a Metro scooter for mobility and now you are out $1,299.00 which you need to be 
reimbursed. 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 reimburse you 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for an electric wheelchair 
purchased on October 1, 2023, from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies provided on August 17, 2023. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid physician order for the supplies provided in this case. Review of the file 
shows that the physician order is not valid as there is no date and no signature from the referring provider. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided on August 
17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (80050) provided May 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 80050 is considered not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 80050 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 80050 is not covered. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory service (80050) provided May 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service August 10, 
2023.  
 
You asked the Plan to pay for procedure code 99239. You say that 99239 should be paid as billed because it 
was rendered at a different facility with a different tax identification number than 99223. The Plan denied your 
request. The Plan says payment for code 99239 is bundled into payment for code 99223. 
 
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 99239 and 99223 were billed by providers of the same specialty and billing group, which is considered the same provider. 
We have also confirmed that code 99239 is a column two code to column one code 99223 with a modifier 
indicator of 0. The column two code is therefore not payable. 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 99239 
billed for date of service August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a telehealth visit provided on September 
12, 2023. 
 
You asked the Plan to waive the coinsurance for a telehealth visit. You say that you think that the provider was 
in-network. 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 47% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 47% coinsurance for a telehealth visit. This item/service falls within the out-of-
network 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 $31.83 ($67.72 
allowed amount x 47% = $31.83 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for a telehealth visit provided on September 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a colonoscopy provided on August 03, 
2023, to August 31, 2023. 
 
You asked the Plan to reduce the copayment for a colonoscopy. You say that this should not have such a large 
copayment. You were advised it would be $35. 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 $200 
copayment for outpatient hospital services. 
 
You have been asked to pay a $200 copayment for a colonoscopy. This item/service falls within the outpatient 
hospital 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 reduce the copayment for a colonoscopy 
provided on August 03, 2023, to August 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 0202U for date of service July 3, 2023. 
 
You asked the Plan to pay for code 0202U. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0202U is infectious disease (bacterial or viral respiratory 
tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory 
syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as 
detected or not detected. 
 
We find that CPT code 0202U is not payable as billed. Specifically, this code has a status indicator of A. This 
means this code is not payable under Outpatient Prospective Payment System (OPPS). No separate payment 
can be made for this service. Based on this information, we decided that Medicare rules for coverage of code 
0202U have not been met. Therefore, we decided that the Plan does not have to pay for code 0202U for date of 
service July 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A4305 and A4223 for date of service June 16, 2023, to 
June 17, 2023. 
 
You asked the Plan to pay for codes A4305 and A4223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the drug delivery system supplies rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps are non-covered devices because they do not meet the Medicare definition of 
durable medical equipment. Drugs and supplies used with disposable drug delivery systems are also non-
covered items. 
 
We looked at the file and Medicare rules. Review of the file shows that the items at issue are a disposable drug 
delivery system and infusion supplies. These items are specifically not covered. Based on this information, we 
decided that Medicare rules for coverage of codes A4305 and A4223 have not been met. Therefore, we decided that the Plan does not have to pay for codes A4305 and A4223 for date of service June 16, 2023, to June 17, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each chiropractic manipulative treatment 
provided on August 03, 2023, to September 12, 2023. 
 
You asked the Plan to waive the copayment for each chiropractic manipulative treatment. You say that you are 
requesting a reconsideration of the Plans denial for 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 $20 
copayment for chiropractic care in a specialists office. 
 
You have been asked to pay a $20 copayment for each chiropractic manipulative treatment. This item/service 
falls within the chiropractic care in a specialists office 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. You have been asked to pay $240 ($20 copayment x 12) for 
each Medicare-covered chiropractic service provided at a specialist's office. Therefore, we decided that the 
Plan does not have to waive the copayment for each chiropractic manipulative treatment provided on August 
03, 2023, to September 12, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide services rendered from June 27, 2023, 
to August 24, 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 Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the home health aide services rendered from June 27, 2023, to 
August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the care planning assessment provided on 
August 01, 2023. 
 
You asked the Plan to pay for an office visit and the care planning assessment. 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 and the 
care planning assessment provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring treatment management 
services (99457) provided on June 30, 2023. 
 
You asked the Plan to pay for the remote physiologic monitoring treatment management services (99457). You 
say that the enrollee does not have the option to choose the provider they see. 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 remote physiologic 
monitoring treatment management services (99457) provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on June 14, 2023, to June 
27, 2023. 
 
You asked the Plan to pay for the wound care services. You say that the services 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 the wound care services 
provided on June 14, 2023, to June 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous minimally invasive sacroiliac (SI) joint 
fusion (27279). 
 
You asked the Plan to pre-approve percutaneous minimally invasive SI joint fusion. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 percutaneous minimally invasive SI 
joint fusion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no SI joint instability fracture or lesion. SI joint 
fusion for degenerative back pain is experimental.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous minimally invasive SI joint fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous minimally invasive sacroiliac (SI) joint 
fusion (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the current wheelchair is not irreparably damaged or more than five years old. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve wheelchair repairs.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intrathecal pain pump to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the intrathecal pain pump. You say that you are requesting reconsideration 
of the denied item. The Plan denied your request. The Plan says the item was 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 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 
the intrathecal pain pump to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flex-walk system or equal lower extremity prostheses 
(L5981). 
 
You asked the Plan to pre-approve flex-walk system. You say that the medical records provided support the 
necessity of the services. The Plan denied your request. The Plan says the current foot is still under warranty. 
Medicare does not cover replacement costs for items still under warranty. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The current foot that was provided in September 2023. This is less 
than six months old and still under warranty. If a new prosthetic foot is needed, the enrollee and vendor need to 
work with the manufacturer to obtain a new one under warranty.  Based on this information, we decided that 
Medicare rules for coverage of flex-walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve flex-walk system or equal lower extremity prostheses (L5981).