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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
17, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 17, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on February 01, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the service 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 lab testing provided 
on February 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) (77080) 
provided on July 31, 2023 
 
You asked the Plan to pay for the DXA. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 77080 was denied 
because this code was not reported with an appropriate diagnosis code. 
 
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 77080 is the dual-energy X-ray absorptiometry (DXA), 
bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine). 
 We find that CPT code 77080 is not supported in the medical record. Specifically, contractors will deny claims 
for screening bone density tests when the claim does not contain a valid diagnosis code from the local lists of 
valid diagnosis codes maintained by the contractor. Based on this information, we decided that Medicare rules 
for coverage of the DXA have not been met. Therefore, we decided that the Plan does not have to pay for the 
dual-energy X-ray absorptiometry (DXA) (77080) provided on July 31, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 14, 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 June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the message therapy to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the message therapy. You say that that this patient would greatly benefit 
from massage therapy for neck and shoulder pain. This service would increase her mobility function. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the message therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refractions (92012, 92015) provided September 18, 2023. 
 You asked the Plan to pay for the refractions. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover refractions. 
 
We looked at the file and the Plan's rules. The plan only covers a medical eye exam. Refractions are not a 
covered benefit. Based on this information, we decided that the Plan's rules for coverage of the refractions have 
not been met. Therefore, we decided that the Plan does not have to pay for refractions (92012, 92015) provided 
September 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for procedures on heart (00562) provided on 
March 27, 2023. 
 
You asked the Plan to pay for the anesthesia. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says code 00560 and 00562 were billed on the same date of service. 
Code 00562 has a Correct Coding Modifier Indicator (CCMI) of "1". This code was not billed with an 
appropriate modifier to bypass the edit. Therefore, code 00562 is not supported. 
 The Plan must follow Medicare rules. Medicare rules say that the National Correct Coding Initiative (NCCI) 
File Formats continue to include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column 
Two Correct Coding edit file. This indicator determines whether an NCCI PTP-associated modifier causes the 
code pair to bypass the edit. The CCMI will be either a "0," "1," or a "9." 
 
We looked at the file and Medicare rules. Code 00562 was billed without an appropriate modifier to bypass the 
NCCI edit. Based on this information, we decided that Medicare rules for coverage of the anesthesia have not 
been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for procedures on heart 
(00562) provided on March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided 
on February 21, 2023, and billed with codes 87798, 87481, and 87551. 
 
You asked the Plan to pay for the wound PCR panel. You say that this testing was not medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided on February 21, 
2023, and billed with codes 87798, 87481, and 87551.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the sales tax (S9999) and the hearing aids 
(V5258) purchased on May 10, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plans denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the sales tax (S9999) and the hearing aids (V5258) purchased on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis-adult (D1110) provided on August 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would truly appreciate reconsideration for 
payment, whether it be retroactively considered in-network or paid at an out-of-network rate. The Plan denied 
your request. The Plan says the 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 the benefit for the requested item or service was exhausted on date of service January 31, 2023. 
Therefore, we decided that the Plan does not have to pay for a prophylaxis-adult (D1110) provided on August 
3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a residence visit provided on May 27, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the residence visit. You say that it was not your responsibility to obtain 
authorization. The Plan denied your request. The Plan says that their original decision to deny payment was 
correct. 
 
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 a residence visit provided on May 27, 2023, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
January 1, 2023 to January 12, 2023 . 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on January 1, 2023 to January 12, 2023 .
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 5, 2023, to 
August 3, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services, a NOA must be submitted for the 
first period of care, using the first date of the period as the admission date. Subsequent claims must report 
this new date as the admission date in order for the claim to be matched to the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA. Based on this information, we find that the Medicare rules for payment 
of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from July 5, 2023, to August 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (36415, 84153, 87086) provided on May 4, 
2023, by an out-of-network (OON) provider.  
 
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 there were network providers available. 
 
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 lab services (36415, 84153, 87086) provided on 
May 4, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face-down positioning support equipment (E1399) 
provided July 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the face-down positioning device. You say that your doctor prescribed renting 
the equipment to ensure that the macular surgery you had would be successful. 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 the face-down positioning support equipment 
(E1399) provided July 19, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic and radiology services provided on May 30, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for practitioner services. You say that these services were necessary to improve your 
quality of life. The Plan denied your request. The Plan says that their original decision to deny payment was 
correct. 
 
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 chiropractic and radiology services provided on 
May 30, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A4649) provided on July 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
without the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claims lines for A4649 billed without A1-A9 
modifiers will be rejected as missing information. 
 
We looked at the file and Medicare rules. In this case, code A4649 was billed without a required modifier. 
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 the services (A4649) provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a cardiac catheterization provided on 
January 10, 2023. 
 
You asked the Plan to reduce the coinsurance for a cardiac catheterization. You say that you should be charge 
the $275 copayment for a procedure, not this 20%. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for a cardiac catheterization. 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. The total you owe is $950.39 ($4751.96 x 20% = 
$950.39). Therefore, we decided that the Plan does not have to reduce the coinsurance for a cardiac 
catheterization provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
June 06, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that your Plan has a $0 
deductible for annual routine eye examinations. You also say that you were not advised this was a medical 
examination. 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 Medicare-covered examinations to diagnose and treat diseases of the eye, including an annual 
glaucoma screening for members at high risk.  
You have been asked to pay a $40 copayment for a medical eye examination. This item/service falls within the 
Medicare-covered examinations to diagnose and treat diseases of the eye, including an annual glaucoma 
screening for members at high risk 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 
medical eye examination provided on June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each wound care services provided on July 
13, 2023, to July 19, 2023. 
 
You asked the Plan to waive the copayment for each wound care services. You say that you want to appeal the 
amount being charged. 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 $275 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $275 copayment for each wound care services. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities 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. 
The total you owe is $550 ($275 copayment x 2 visits = $550). Therefore, we decided that the Plan does not 
have to waive the copayment for each wound care services provided on July 13, 2023, to July 19, 2023.