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

 
We decided that the Plan does not have to pay for procedure codes 57282 and 52000 billed for date of service 
August 1, 2023. 
 
You asked the Plan to pay for procedure codes 57282 and 52000. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says payment for codes 57282 and 52000 
is bundled into payment for codes 58260 and 57260. In addition, surgical assistant services are not covered for 
code 52000. 
 
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 
57282 and 52000 are column II codes to column I codes 58260 and 57260. This claim has not been billed with 
an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not 
been met. 
 
In addition, Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon 
services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology 
(CPT) code 52000. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. 
This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid.  Therefore, we decided that the Plan does not have to pay for procedure codes 57282 and 52000 billed for 
date of service August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry office visits provided on June 
15, 2023, and June 29, 2023. 
 
You asked the Plan to waive the copayment for the podiatry office visits. You say that you have never had to 
pay a copayment with this provider before. 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 each in-network podiatry visit.  
 
You have been asked to pay a $40 copayment for each podiatry office visit. These services fall within the 
podiatry 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 the podiatry office 
visits provided on June 15, 2023, and June 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient surgery (88173, 88313, 
10005) provided on September 12, 2023. 
 
You asked the Plan to reduce the copayment for the outpatient surgery (88173, 88313, 10005). You say that 
your copayment should only be $240. 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 $375 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and and 
ambulatory surgical centers.  
You have been asked to pay a $375 copayment for the outpatient surgery (88173, 88313, 10005). This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
and ambulatory surgical centers 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 
the outpatient surgery (88173, 88313, 10005) provided on September 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gocovri capsule. 
 
You asked the Plan to pre-approve Gocovri. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Gocovri 
capsule.  
 
Benefits for Gocovri may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroablation (64640). 
 
You asked the Plan to pre-approve neuroablation. 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 neuroablation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the safety and efficacy, as defined by Medicare rules, 
of the requested service. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuroablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neuroablation (64640).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility care provided on May 12, 2023, to 
May 26, 2023. 
 
You asked the Plan to pay for the skilled nursing facility care. You say that the assisted living facility is 
responsible to obtain prior authorization for all their patients. 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 skilled nursing 
facility care provided on May 12, 2023, to May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 01, 
2023, to June 08, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
facility care provided on June 01, 2023, to June 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0391U) provided on September 18, 2023. 
 
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 claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0391U) provided on 
September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 17, 2023, to July 
31, 2023. 
 
You asked the Plan to pay for the home health services. You say that you are asking the plan to process the 
claim for available benefits based on the attached medical records. 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 home health services 
provided on July 17, 2023, to July 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 or date of service July 31, 2023. 
 
You asked the Plan to pay for procedure code 81456. 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. 
 
In this case, the CPT Code Manual definition of code 81456 is argeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm or disorder, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, 
DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MET, MLL, NOTCH1, NPM1, 
NRAS, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy 
number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA 
analysis.  
We find that CPT code 81456 is not supported in the medical record. Specifically, no medical records were 
provided for review. This means the documentation does not support how the enrollee came to the servicing 
provider, whether the billed services were actually performed, or that the services were medically necessary. 
Based on this information, we decided that Medicare rules for coverage of procedure code 81456 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 81456 or date of service July 
31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 17, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood draw and an office visit provided on May 18, 2023. 
 
You asked the Plan to pay for a blood draw and an office visit. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a blood draw and an 
office visit provided on May 18, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the occupational therapy (97165, 97110) 
provided on July 5, 2023. 
 
You asked the Plan to reduce the copayment for the occupational therapy (97165, 97110). You say that you are 
requesting this claim be reprocessed for payment leaving the enrollee a $25 copayment. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to occupational therapy (97165, 
97110).  
 
The item or service you asked the Plan to reduce the copayment for falls within the What is your plan 
deductible? benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $1000 deductible which applies to occupational therapy. This cost sharing is a contractual obligation 
that had not been met at the time the occupational therapy (97165, 97110) was received on July 5, 2023. Therefore, we decided that the Plan does not have to reduce the copayment for the occupational therapy 
(97165, 97110) provided on July 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
unit from an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that the enrollee has been prescribed this device. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
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 
a transcutaneous electrical nerve stimulation (TENS) unit from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for a power wheelchair. 
 
You asked the Plan to pre-approve repairs for a power wheelchair. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says repairs for DME still under 
warranty are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payments for repair and maintenance may not 
include payment for parts and labor covered under a manufacturers or suppliers warranty.  
 
The case record shows that the enrollee's equipment is still under warranty. Therefore, we decided that the Plan 
does not have to pre-approve repairs for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on July 19, 2023. 
 
You asked the Plan to pay for the drug testing. 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 drug testing 
provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to provide additional reimbursement for Platelet rich plasma (PRP) injections you 
received on April 25, 2023. 
 
You asked the Plan to provide additional reimbursement for the PRP injections. You say that you were advised 
these injections were covered, and were disappointed in the amount you were reimbursed. The Plan denied 
your request. The Plan says that you have been reimbursed the Medicare-allowed amount, minus your cost 
sharing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has failed to support how and why it coded and paid this 
claim in the manner it did. Specifically, it appears that the Plan somehow decided to assign procedure codes 
20610 and 99070 to the PRP injections you received.  (Note that your appeal request did seem to indicate that 
code 20610 may be involved, but your appeal request ALSO included code 0232T, which the Plan failed to 
address.) The Plan has provided no explanation as to how or why it used those codes. Those are not the 
appropriate codes to designate the use of PRP injections. Rather, codes 0232T, P9020 and G0460 should be 
used for PRP injections. It does not appear that the Plan made any efforts or attempts to get medical records or 
claims from the provider to show which of these codes should have been billed. In addition, payment for PRP 
injections also requires medical evidence of the number of units of PRP actually injected. Again, the Plan has 
documented no efforts made to obtain the number of units of PRP that were injected, so it is unclear how the 
Plan would be able to determine the payable amount for the PRP injections you received. 
 
The burden is on the Plan to show why is decisions and payments were correct. By failing to even attempt to 
get medical records to support its assignment of codes 99070 and 20610 to the PRP injections you received 
(which, again, do not remotely match up to the codes that should be used for PRP injections), we find that the 
Plan has not met this burden. Therefore, we decided that the Plan has to provide additional reimbursement for 
Platelet rich plasma (PRP) injections you received on April 25, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01942) provided April 20, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that please review the attached documentation 
and reconsider reprocessing for payment as the claim was submitted with a valid diagnosis. The Plan denied 
your request. The Plan says diagnosis of M80.08XA does not support medical necessity. 
 
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 01942 is anesthesia for percutaneous image-guided 
neuromodulation or intravertebral procedures (e.g., kyphoplasty, vertebroplasty) on the spine or spinal cord. 
 
We find that CPT code 01942 is not supported in the medical record. Specifically, the claim was billed with 
diagnosis code M80. 08 for Age-related osteoporosis with current pathological fracture, vertebra(e). This diagnosis code is not listed under the Group 1 codes in Local Coverage Article Billing and Coding: Monitored 
Anesthesia Care A57361 as a diagnosis code that supports medical necessity.  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 the anesthesia services (01942) provided April 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652. 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that a PCD coded as E0652 is not covered for the treatment 
of lymphedema of the extremities alone even if the criteria are met. 
 
We looked at the file and Medicare rules. The records do not document lymphedema extending into the chest 
or trunk for the enrollee. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (PCD) described by code E0652.