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

 
We decided that the Plan does not have to pay for medical services provided on January 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON medical services. You say that this patient has been treated in your 
office since 2021 for this osteoarthritis of both knees. You say that when the enrollee changed insurance plans 
in November of 2022, you billed the new Plan and two claims were paid. You say that, after this, you would 
have had no reason to believe that the services in dispute would not be paid as well. The Plan denied your 
request. The Plan says the OON services provided were not pre-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 medical services provided on January 18, 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 a wheelchair seat cushion (E2622) provided on May 16, 
2023. 
 
You asked the Plan to pay for the wheelchair seat cushion. You say that this item was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines for wheelchair seat cushions billed 
without a KX modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The claim was not billed with the required KX modifier. Based on 
this information, we decided that Medicare rules for coverage of the wheelchair seat cushion have not been 
met. Therefore, we decided that the Plan does not have to pay for a wheelchair seat cushion (E2622) provided 
on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tetanus, Diphtheria Toxoids and Acellular Pertussis 
vaccine provided on April 27, 2023. 
 
You asked the Plan to pre-approve Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that 
you were due for the shot. The Plan denied your request. The Plan says immunizations are not covered unless 
they are directly related to the treatment of an injury or direct exposure to a disease or condition. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pre-
approve Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service June 29, 
2023. 
 
You asked the Plan to pay for procedure code 96040. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 96040 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 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 96040 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96040 billed for date of service June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 31, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically  necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological medical exam provided on March 31, 
2023. 
 
You asked the Plan to pay for ophthalmological medical exam. You say that you are requesting reconsideration 
for 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 ophthalmological 
medical exam provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 14, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for April 21, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed diagnosis codes are not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the billed diagnosis codes indicate left and right 
laterality while a more appropriate bilateral diagnosis should have been reported. Therefore, we decided that 
the Plan does not have to pay for procedure code 99285 billed for April 21, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a laparoscopic sleeve gastrectomy. 
 
You asked the Plan to pre-approve a laparoscopic sleeve gastrectomy. You say that a laparoscopic sleeve 
gastrectomy is medically necessary. The Plan denied your request. The Plan says that under Medicare 
guidelines, your request is not medically necessary because your records show you have chronic interstitial 
lung disease/pulmonary fibrosis with plans for lung transplant. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a laparoscopic sleeve gastrectomy. Our 
reviewer says that the requested laparoscopic sleeve gastrectomy is considered medically reasonable and 
necessary in this case. Our physician reviewer found you have interstitial lung disease and you are requesting 
authorization for coverage for bariatric surgery to lose weight for lung transplant eligibility. In solid organ 
transplant, use of bariatric surgery to achieve transplant candidacy is fairly routine in properly selected patients 
and in some cases, may even reverse the need for transplant. Bariatric surgery for you is medically necessary 
and end-stage organ disease is only a relative contraindication when transplant for that organ is a possibility. 
 
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 laparoscopic sleeve gastrectomy have been met. Therefore, we decided that 
the Plan has to pre-approve a laparoscopic sleeve gastrectomy.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on June 2, 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 June 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray rendered on June 14, 2023. 
 
You asked the Plan to pay for these services. You say that the services are not related to workers' 
compensation. The Plan denied your request. The Plan says this is a workers' compensation claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for workers' compensation 
claims. 
 
We looked at the file and Medicare rules. The file shows that the x-ray was related to a workers' compensation 
injury. Therefore, we decided that the Plan does not have to pay for the x-ray rendered on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2023. 
 
You asked the Plan to pay for the office visit. You say that you only received manipulations from the provider. 
The Plan denied your request. The Plan says that the Plan only covers manual manipulation of the spine to 
correct subluxation. Other services performed by a chiropractor are not covered.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on June 14, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services rendered from May 24, 2022, to 
May 31, 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 that the PDPM was changed from GEXD1 to GDXD1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 supported by the medical records. Our reviewer found that the enrollee was not ordered a 
therapeutic diet, but a regular diet.  The enrollee was, however, ordered a mechanically altered diet, in the form 
of a mechanically soft texture diet.  As such, the billed code is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
skilled nursing facility (SNF) services rendered from May 24, 2022, to May 31, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services (77063, 77067). provided on April 
12, 2023. 
 
You asked the Plan to pay for mammography services (77063, 77067).. You say that the services at issue were 
a medical necessity for the enrollee. 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 mammography services 
(77063, 77067). provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous needle biopsy of the liver (47000) and 
ultrasonic guidance for needle placement (76942) to be provided by an out-of-network (OON) tertiary provider.  
 
You asked the Plan to pre-approve the liver biopsy. You say that only certain doctors are specialized in the 
process and that is why your doctors want to send you to this facility. 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 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. The Plan has approved for you to have the 
liver biopsy at an in-network facility. 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 percutaneous needle 
biopsy of the liver (47000) and ultrasonic guidance for needle placement (76942) to be provided by an out-of-
network (OON) tertiary provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx UTI-ABR Molecular Test Panel provided on 
October 14, 2022, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the Altru Dx UTI-ABR Molecular Test Panel. You say that this testing was 
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 a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Altru Dx UTI-ABR Molecular Test Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx UTI-ABR 
Molecular Test Panel provided on October 14, 2022, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on June 7, 2023, billed with 
codes 87481, 87798, 87640, 87653, 87556, 87651, 87150, 87500 and 87641. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on June 7, 2023, billed with codes 87481, 87798, 87640, 87653, 87556, 87651, 87150, 87500 
and 87641.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional therapy service (97802, 97803). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve nutritional therapy service (97802, 97803).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 12, 2022, billed 
with procedure code 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the requested supporting documentation has not been provided for review. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on December 12, 2022, billed 
with procedure code 99232.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87563, 87640, 87653, 87798, 
87641, 87500) provided on May 24, 2023. 
 
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 coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 are not supported in the 
medical record. Specifically, multiple unbundled codes were billed for a single panel. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87481, 87491, 87563, 87640, 87653, 87798, 87641, 
87500) provided on May 24, 2023.