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 October 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services provided 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 an office visit provided 
on October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for routine foot care provided on April 27, 2022. 
 
You asked the Plan to pay for the routine foot care. You say that you had your toenails cut as you cannot reach 
them anymore. You say that as your toenails grew, they changed shape and a couple now work their way into 
the skin at the end, which causes bleeding in the skin. The Plan denied your request. The Plan says the provider 
did not bill with a diagnosis that states you have a condition that affects your lower limbers. In addition, you 
signed an insurance waiver prior to receiving services advising that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot 
care provided on April 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on December 29, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service June 24, 
2022. 
 You asked the Plan to pay for procedure code 99223. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99223 is bundled into payment for code 33361. 
 
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 99223 
is a column II code to column I code 33361. 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 99223 billed for date of service June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 4, 2022, billed with 
code 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that an excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the excludes1 note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was billed with diagnosis codes 
R06.00 and J96.01 which is a code pair that is subject to an excludes1 note and cannot be billed together. Therefore, we decided that the Plan does not have to pay for practitioner services provided on August 4, 2022, 
billed with code 99232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network neck injection procedure 
provided on December 06, 2022. 
 
You asked the Plan to waive the copayment for an in-network neck injection procedure. You say that you want 
this bill reviewed and taken off. You have had similar procedures before and didnt get a bill this high. 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 $260 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical center.  
You have been asked to pay a $260 copayment for an in-network neck injection procedure. This item/service 
falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical center 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 an in-
network neck injection procedure provided on December 06, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2023, to 
February 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely filed this claim. 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 that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, 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 which is filed for the first date in 2022 as required. 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 January 12, 2023, to 
February 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 28, 2022, to 
October 31, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you submitted the NOA 
timely. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 28, 2022. The NOA was not received by the Plan until January 
26, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Please note that the documentation you submitted indicates that the NOA you submitted on 
October 3, 2022, was rejected. There is no evidence that a valid, non-rejected NOA was submitted prior to 
January 26, 2023. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 28, 2022, to October 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 19, 2022, to 
March 20, 2022. 
 You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 20, 2022. The NOA was not received by the Plan until April 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 19, 2022, to March 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says a kyphoplasty is 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 a kyphoplasty. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the July 7, 2023, computed tomography (CT) scan of the lumbar spine states the L2 compression 
fracture is age-indeterminate; however, it appears to be subacute. There is no indication of a progression of 
body-height loss, greater than 25% vertebral body height loss, kyphotic deformity or a severe impact on the 
enrollee's daily activities. Moreover, there are other plausible causes of the low-back pain demonstrated on 
exam and diagnostic imaging. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty procedure (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is under your care for polymyalgia 
rheumatica. You also say that the standard of care for treatment of this disease is low dose prednisone. 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 drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone.  
 
Benefits for the medication 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says physical therapy services are available within your 
health Plan or medical group provider network.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by the requested out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2011 billed for date of service February 23, 
2023. 
 
You asked the Plan to pay for procedure code H2011. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 H2011 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2011 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2011 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2011 billed for date of service February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the telehealth services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the telehealth services. You say that the service should be covered. The Plan 
denied your request. The Plan says this services was obtained out-of-network. 
 
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 telehealth services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus liquid biopsy xF (88305) provided February 14, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of this 
determination and coverage of the Tempus Liquid Biopsy xF CGP panel test at the in-network benefit level. 
The Plan denied your request. The Plan says the requested test is not reasonable and necessary because Tempus 
xF has not had FDA approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer. 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 Tempus liquid biopsy xF (88305) provided February 14, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided January 
5, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you provided the services to the 
enrollee as per the physician's prescription. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
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 January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI testing provided on February 25, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the Guidance UTI testing. You say that this test was ordered by the enrollees 
physician. The Plan denied your request. The Plan says this test is not covered when provided OON. 
 
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 Guidance UTI testing provided on February 
25, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87481, 87798) provided on October 5, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that please see attached medical record 
reconsideration. 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 laboratory service (87481, 87798) provided on 
October 5, 2022, 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 pneumatic compression device provided on February 7, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided January 
12, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you provided the service the 
enrollee to per their physician prescription. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
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 January 12, 2023.