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

 
We decided that the Plan does not have to provide reimbursement for the office visits, psychotherapy, and 
ketamine infusions provided from March 6, 2023, to April 20, 2023, by an out-of-network provider. 
 
You asked the Plan to provide reimbursement for the office visits, psychotherapy, and ketamine infusions. You 
say that you had to receive these services outside the Plan's service area due to your panic attacks and high 
depressive state. The Plan denied your request. The Plan says these services were not authorized. 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 provide reimbursement for the office visits, 
psychotherapy, and ketamine infusions. Our reviewer says that these services were not medically necessary to 
be provided out-of-network. Our physician reviewer found that you did not require immediate emergency 
treatment based on the documentation by the out-of-network provider. Based on the documentation provided it 
is assumed you can be treated by an in-network provider for treatment services. Utilization of in-network 
providers assures a credentialed and clinically maintained individual assured by the medical provider to a 
specified standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visits, psychotherapy, and ketamine infusions have not been met. 
Therefore, we decided that the Plan does not have to provide reimbursement for the office visits, 
psychotherapy, and ketamine infusions provided from March 6, 2023, to April 20, 2023, by an out-of-network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 1, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 22, 2022, billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 81306-59, 81328-59, 
81335-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. The clinical value and effectiveness of 
comprehensive pharmacogenetic testing have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 22, 2022, billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 
81291-59, 81306-59, 81328-59, 81335-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased on September 3, 2022. 
 
You asked the Plan to pay for the walker. You say that you were not aware that you had to use a Medicare-
certified provider. The Plan denied your request. The Plan says you purchased this item from a provider that is 
not Medicare-certified. 
 
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 the walker you purchased on September 
3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0326U) billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says the provided records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 genetic testing have been met. 
Specifically, laboratory reports for the date of service at issue have not been provided for review. Therefore, we 
decided that the Plan does not have to pay for genetic testing (0326U) billed for date of service August 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on June 15, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) billed for date of service February 16, 
2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 drug testing have been met. 
Specifically, the case record does not contain a physician order or requisition for the services at issue. 
Therefore, we decided that the Plan does not have to pay for drug testing (G0482) billed for date of service 
February 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have waive part of the cost share for the advanced imaging provided in an 
outpatient hospital facility on June 5, 2023. 
 
You asked the Plan waive part of the cost share for the advanced imaging. You say that you do not agree that 
this service was rendered at a hospital. 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 $150 
copayment for Outpatient diagnostic tests.  
 
You have been asked to pay a $150 copayment for the advanced imaging. This service falls within the Outpatient diagnostic tests benefit category. The file indicates that this service was provided in an outpatient 
hospital facility. 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 waive part of the cost share for the advanced imaging 
provided in an outpatient hospital facility on June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 10, 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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy visit provided on 
May 24, 2023, to July 18, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy visit. You say that you were told these 
services were covered with no cost share. 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 $40 
copayment for in-network outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. This item/service falls within the 
in-network outpatient rehabilitation 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. However, you have been asked to pay $24.35, which is less than the 
standard copayment for the physical therapy visit on June 2, 2023. Therefore, we decided that the Plan does not 
have to waive the copayment for each physical therapy visit provided on May 24, 2023, to July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a manual wheelchair provided on May 17, 
2023. 
 
You asked the Plan to waive the coinsurance for a manual wheelchair. You say that you say that you already 
paid. 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 (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for a manual wheelchair. 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. The total you owe is $122.81 ($613.97 allowed amount x 
20% = $122.81). Therefore, we decided that the Plan does not have to waive the coinsurance for a manual 
wheelchair provided on May 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the laparoscopic surgery (43659) provided 
in an outpatient hospital setting from May 19, 2023, to May 21, 2023. 
 
You asked the Plan to waive the cost share for the outpatient surgery. You say that you had major surgery and 
spend two nights in the hospital. You say that you were billed a $225 copayment (copay). You say that your 
coverage shows there is no copay if in hospital admitted to hospital. You also say that you have requested that 
the provider resubmit the claim with the correct coding for an in-hospital procedure. 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 $225 
copayment for Outpatient hospital surgery services.  
 You have been asked to pay a $225 copayment for the laparoscopic surgery. This service falls within the 
Outpatient hospital surgery 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 cost share for the 
laparoscopic surgery (43659) provided in an outpatient hospital setting from May 19, 2023, to May 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided on July 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 25, 2021. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210) provided on July 11, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH services to 
regain their prior level of functioning and preserve their functional independence. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, G0155, Q5001, G0156) 
provided on November 9, 2022 to November 17, 2022. 
 
You asked the Plan to pay for the home health 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 codes G0299, G0155, Q5001, & G0156 are not supported in the medical record. Specifically, 
F01.C3 is not a valid primary diagnosis code as of the date of service. Based on this information, we decided 
that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the 
Plan does not have to pay for home health services (G0299, G0155, Q5001, G0156) provided on November 9, 
2022 to November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BaroStim Neo device provided on June 6, 2023. 
 
You asked the Plan to pay for the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Barostim Neo System in the setting of 
congestive heart failure have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in your clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pay for the BaroStim Neo device provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an out-of-network provider. The Plan 
denied your request. The Plan says the member's needs can be met by an innetwork provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 28, 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 April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-
TC, 95865-TC, 95937-TC, and 95940 billed for date of service January 31, 2023. 
 
You asked the Plan to pay for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95865-TC, 
95937-TC, and 95940. You say that the claim is billed correctly and should be paid. The Plan denied your 
request. The Plan says these codes are included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95939-TC, 95938-TC, 
95927-TC, 95861-TC, 95865-TC, 95937-TC, and 95940. This means there is both a professional and technical 
component for the CPT code(s). In this case, an appropriate modifier to indicate the professional component 
has not been billed with CPT code(s) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95865-TC, 95937-TC, and 
95940. Based on this information, we decided that Medicare rules for coverage of procedure code 95939-TC, 
95938-TC, 95927-TC, 95861-TC, 95865-TC, 95937-TC, and 95940 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95865-
TC, 95937-TC, and 95940 billed for date of service January 31, 2023.