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

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
November 21, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the patient had multiple exams on 
this date of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on January 15, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the emergency department visit have not been met.  
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
November 21, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for an emergency department visit provided on 
September 11, 2022. 
 
You asked the Plan to pay for physician's services for an emergency department visit. You say that you have 
provided proof of enrollment from CMS for this provider.  The Plan denied your request. The Plan says under 
federal regulations, the Medicare Advantage Plan is prohibited from paying claims for care provided to our 
Medicare Advantage Plan members by providers who have been excluded from participating in federal 
programs at the time services were rendered. 
 
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. Specifically, the Plan has not provided documentation showing that this 
physician (NPI 1285083519) and/or the billing group (NPI 1861430555) have been precluded from 
participation in Medicare at the time services were rendered. Therefore, we decided that the Plan has to pay for 
physician's services for an emergency department visit provided on September 11, 2022.   
 
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 physician's services provided on January 9, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on October 3, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was 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 nursing facility care provided on October 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for an emergency department visit provided on 
June 14, 2022. 
 
You asked the Plan to pay for physician's services for an emergency department visit. You say that you have 
provided proof of enrollment from CMS for this provider. The Plan denied your request. The Plan says that the 
Medicare Advantage Plan is prohibited from paying claims for care provided to our Medicare Advantage Plan 
members by providers who have been excluded from participation in federal programs at the time services 
were rendered. 
 
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. Specifically, the Plan has not provided documentation showing that this 
physician (NPI 1285083519) and/or the billing group (NPI 1861430555) have been precluded from 
participation in Medicare at the time services were rendered. Therefore, we decided that the Plan has to pay for 
physician's services for an emergency department visit provided on June 14, 2022.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from March 7, 2022, to 
November 1, 2022. 
 
You asked the Plan to reimburse you for the psychotherapy. You say that in the past, the Plan has approved and 
paid out on the visits to this provider regardless of his not accepting Medicare funds. The Plan denied your 
request. The Plan says you got these services from a provider who chose not to receive Medicare funds.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from March 7, 2022, to November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services and supplies provided from September 1, 
2022, to September 23, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services and supplies. You say that this should be covered. The Plan 
denied your request. The Plan says this was 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 laboratory services and supplies provided from 
September 1, 2022, to September 23, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection procedure; radioactive tracer for identification of 
sentinel node rendered on November 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 38792-59-LT is not supported by the medical records submitted. 
 
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 38792 is "Injection procedure; radioactive tracer for 
identification of sentinel node." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the procedure report does not 
include sufficient documentation to confirm radioactive tracer for identification of sentinel node has been 
performed. The code is not supported by the records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection procedure; radioactive tracer for identification of sentinel node rendered on November 
7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 28 fractions of proton beam radiation therapy with 
image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than Intensity-modulated radiation therapy/Image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. While NCCN guideline consider proton therapy a reasonable 
alternative they do not describe it as being necessary in lieu of non-proton-based treatment and are quite 
explicit in that there is no evidence of its superiority. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 28 fractions of proton beam radiation therapy with image-guided 
radiation therapy (IGRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tenodesis of long tendon of biceps rendered on October 26, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 23430 is considered inclusive to CPT 23472. 
 
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 23430 is "Tenodesis of long tendon of biceps." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure details cite the rotator cuff was intact, as the long head of the biceps tendon, (which was securely tenodesed in its groove with 
No.2 Orthocord prior to being released where it entered the joint.) However, this was performed as part of the 
total shoulder arthroplasty. The tenodesis was performed prior to being released where it entered the joint. 
Therefore, the records do not support that CPT 23430: tenodesis of long tendon of biceps was a separate and 
distinct procedure from CPT 23472: arthroplasty, glenohumeral joint, total shoulder (glenoid and proximal 
humeral replacement (e.g., total shoulder)).  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for tenodesis of long tendon of biceps rendered on October 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 21, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the inpatient facility 
payment. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient to the origin location provider. The record did not include adequate documentation 
showing that the enrollee was discharged from the original provider when transported to another provider. This 
means that the ambulance service appears to be covered as an inpatient hospital service and is not separately 
billable. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on 
August 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
October 31, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that this should be paid for. The Plan 
denied your request. The Plan says procedure code 20930 and 20936 is considered bundled and not separately 
payable.  
 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 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. This 
means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of mini-implants on tooth #25 
and 27 (D6013). 
 
You asked the Plan to pre-approve the dental services. You say that you have not had these services yet this 
year. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on this authorization request. Therefore, 
we decided that the Plan does not have to pre-approve the surgical placement of mini-implants on tooth #25 
and 27 (D6013).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xT Solid Tumor gene panel test (81455) provided on 
November 15, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Tempus xT Solid Tumor gene panel test (81455) 
provided on November 15, 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 genetic testing coded as 81220, 81329 and 81420 
provided November 22, 2022. 
 
You asked the Plan to pay for  the genetic testing. You say that you are requesting reconsideration and payment 
in full for the test performed on the basis that the test ordered was medically necessary. The Plan denied your 
request. The Plan says under Medicare rules, this request is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules explicitly say that screening tests, with the exception of the 
few tests listed in the Medicare rules section, are not covered. 
 
We looked at the file, and Medicare rules.  There is no diagnosis of an advanced cancer which would warrant 
testing by Next Generation Sequencing (NGS). The test performed have not completed a MolDx technical 
assessment to meet the Medicare criteria for reasonable and necessary, and these tests are not Medicare covered 
screening tests. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for  the genetic testing coded as 
81220, 81329 and 81420 provided November 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93312-26 billed for date of service April 20, 
2022. 
 You asked the Plan to pay for procedure code 93312-26. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 93312-26 is bundled into payment for 
code 00534. 
 
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 code 
93312-26 is a column II code to column I code 00534. 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.  
Therefore, we decided that the Plan does not have to pay for procedure code 93312-26 billed for date of service 
April 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on January 18, 2023, billed with 
code 0241U-QW. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. 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 the testing services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for testing services 
provided on January 18, 2023, billed with code 0241U-QW.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine exam 
provided on October 3, 2022. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine exam. You say that a yearly 
gynecological exam is medically necessary as you had ovarian cancer when you were 30 years of age, and you 
are at a higher risk. The Plan denied your request. The Plan says you had an annual physical exam with your 
Primary Care Provider on September 7, 2022; therefore, you have exceeded the benefit limit. 
 
The Plan contract says an annual physical exam is limited to one exam per calendar year. 
 
We looked at the file and Medicare rules. The file shows that you have exceeded the maximum benefit limit. 
Therefore, we decided that the Plan does not have to pay for a periodic comprehensive preventive medicine 
exam provided on October 3, 2022.