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

 
We decided that the Plan does not have to pay for an office visit provided on November 18, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the claims should be paid since teh services were 
done in good faith. The Plan denied your request. The Plan says services from non-participating proviers are 
not covered unless preauthorized. 
 
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 an office visit provided on November 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 30, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting to reconsider the claim for 
payment and seeking for review. The Plan denied your request. The Plan says the services are not authorized 
because the requested provider is a non-network provider who does not work with the enrollee's health Plan. 
 
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 an office visit provided on September 30, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON services. You say that the test is used to determine the appropriate 
treatment. The Plan denied your request. The Plan says utilization of network providers and authorization for 
certain services are required. 
 
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. 
 
We looked at the file, and Medicare rules. The provider at issue 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 pay for the OON services. Based on this information, we decided 
that Medicare rules for coverage of the OON services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on March 23, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87498, 87502, 87541, 87581, 87640, 
87641, 87651, and U0005 for date of service March 21, 2023. 
 
You asked the Plan to pay for procedure codes 87486, 87498, 87502, 87541, 87581, 87640, 87641, 87651, and 
U0005. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services billed are not supported.  
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 87486, 87498, 87502, 87541, 87581, 87640, 87641, 87651, and U0005 are not 
supported in the medical record. Specifically, the submitted medical records do not include an order that 
specifically lists what test(s) are to be performed in the custom panel. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 87486, 87498, 87502, 87541, 87581, 87640, 87641, 
87651, and U0005 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 87486, 87498, 87502, 87541, 87581, 87640, 87641, 87651, and U0005 for date of service March 21, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services and remote physiologic 
monitoring treatment management services provided on March 31, 2023. 
 
You asked the Plan to pay for chronic care management services and remote physiologic monitoring treatment 
management 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 chronic care 
management services and remote physiologic monitoring treatment management services provided on March 
31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36011 and 75822 billed for date of service 
January 19, 2023. 
 
You asked the Plan to pay for procedure codes 36011 and 75822. 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 codes 
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 36011 is: Selective catheter placement, venous system; 
first order branch (eg, renal vein, jugular vein). 
 
Additionally, in this case, we have confirmed that code 75822 is a column II code to column I code 37238; 
however, 75822 was billed with a modifier. 
 
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 procedure codes 36011 and 75822. Our reviewer says that 
procedure codes 36011 and 75822 do not meet criteria for payment. Our reviewer found that for procedure 
code 36011, the provided procedure report does not include documentation of Selective catheter placement, 
venous system; first order branch (eg, renal vein, jugular vein). This procedure was not found in operative 
report, and therefore code 36011 cannot be verified. For procedure code 75822, although the procedure is 
documented in operative report, an intervention was performed which includes radiological supervision. 
Therefore, procedure code 75822 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 procedure codes 36011 and 75822 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 36011 and 75822 billed for date of service January 19, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a speech generating software program (E2511). 
 
You asked the Plan to pre-approve a speech generating software program. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that claims for more than one SGD will be denied as not 
reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a speech generating software program. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the device and 
mounting system approved by the Plan already includes the software, so the request for code, E2511 is 
redundant and will be considered not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a speech generating software program have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a speech generating software program (E2511).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging scan 
provided on May 02, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging scan. You say that you were 
unable to complete the service. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for a magnetic resonance imaging scan. 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. Th record shows that services were 
discontinued and then finalized the same day. Therefore, we decided that the Plan does not have to waive the 
copayment for a magnetic resonance imaging scan provided on May 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 13, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that the test is a Medicare covered service. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules 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 MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 32 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided, correctly 
coded, and medically necessary. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87798 billed for date of service March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracapsular cataract removal with insertion of intraocular 
lens prosthesis provided on November 22, 2022. 
 
You asked the Plan to pay for extracapsular cataract removal with insertion of intraocular lens prosthesis. 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 extracapsular cataract 
removal with insertion of intraocular lens prosthesis provided on November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee has a mobility limitation 
due to a neurological condition. You also say that the enrollee is unable to perform independent pressure relief, 
leaving them at risk of developing pressure ulcers and infections. The Plan denied your request. The Plan says 
the upgraded electronics are not medically necessary. 
 
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 the upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that an expandable controller is an electronic system that is capable of 
accommodating one or more additional features and can operate three or more powered seating options. The 
requested electrical accessories are not medically necessary as the member does have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Therefore, the reviewer found that the upgraded electronics are not medically reasonable or 
necessary. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801 (x3), 87150, 87481, 87641, 87653 
and 87798 billed for date of service January 10, 2023. 
 
You asked the Plan to pay for procedure codes 87801 (x3), 87150, 87481, 87641, 87653 and 87798. You say 
that these services are supported in the medical record. The Plan denied your request. The Plan says these 
codes are not supported 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, we have confirmed that codes 87150, 87481, 87641, 87653 and 87798 are column II codes to 
column I codes 87500 and/or 87801; however, 87150, 87481, 87641, 87653 and 87798 were each billed with a 
modifier.  
 
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 procedure codes 87801 (x3), 87150, 87481, 87641, 87653 
and 87798. Our reviewer says that these codes are not supported as billed. Our reviewer found three units of 
code 87801 was reported; however, this procedure code represents a multiple organisms panel. Only one unit 
of service would be billed for the procedure when the same methodology is performed. In addition, codes 
87150, 87481, 87641, 87653 and 87798 were reported with modifier XU to indicate they were unusual non-
overlapping services and to bypass the NCCI edit. However, the laboratory report does not include 
documentation to support that these services were unusual non-overlapping services independent of the primary 
procedures. Therefore, the use of the XU modifier and separate reporting of these codes are not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87801 (x3), 87150, 87481, 87641, 87653 and 87798 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87801 (x3), 87150, 
87481, 87641, 87653 and 87798 billed for date of service January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three units of procedure code 87801 billed for date of service 
March 16, 2023. 
 
You asked the Plan to pay for three units of 87801. You say that these services are supported as billed. The 
Plan denied your request. The Plan says this code is not supported for the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 three units of 87801 Our reviewer says that 87801 is not supported for three units. Our physician reviewer found CPT 87801 is considered a panel code and 
reported for multiple organisms.  The laboratory report does not support three different methodologies for the 
services provided. Therefore, only one unit of service should be reported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of three units of 87801 have not been met. Therefore, we decided that the Plan 
does not have to pay for three units of procedure code 87801 billed for date of service March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick, and pride adapter plate (K0108). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick, 
and pride adapter plate (K0108). You say that the requested expandable controller (E2377), expandable 
controller harness (E2313), electronic connection (E2311) to control power tilt, recline and power elevating leg 
rests through the joystick, and pride adapter plate (K0108) are medically necessary. The Plan denied your 
request. The Plan says the requested expandable controller (E2377), expandable controller harness (E2313), 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick, 
and pride adapter plate (K0108) are not medically necessary. 
 
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 an expandable controller (E2377), 
expandable controller harness (E2313), electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick, and pride adapter plate (K0108). Our reviewer says that the requested 
expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick, and pride adapter plate (K0108) 
are not medically necessary. Our physician reviewer found the member does have use of the upper extremity 
and can operate and control the power options using the switches that are included in the basic wheelchair. 
There is not a medical need for the upgraded electronics.  Additionally, the requested pride adapter plate would 
be considered a duplication as the authorized power wheelchair has these parts included. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller (E2377), expandable controller harness (E2313), 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick, 
and pride adapter plate (K0108) have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), expandable controller harness (E2313), electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick, and pride adapter plate 
(K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on June 08, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you 
disagree with the cost share applied. 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 $300 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $300 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 a magnetic resonance imaging (MRI) provided on June 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy procedure provided on January 10, 
2023. 
 
You asked the Plan to waive the copayment for a biopsy procedure. You say that the biopsy was performed at 
the doctors office. 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 biopsy procedure. 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. The record shows the service was billed by a hospital. Therefore, we decided that the Plan 
does not have to waive the copayment for a biopsy procedure provided on January 10, 2023.