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

 
We decided that the Plan does not have to pay for the laboratory services coded as G2023, 99001, U0005 and 
U0003 provided on February 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that kindly process the claim towards payment. 
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 services coded as G2023, 99001, 
U0005 and U0003 provided on February 10, 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 procedure code 99358 billed for date of service March 21, 
2023. 
 
You asked the Plan to pay for procedure code 99358. You say that you believe that this code was billed 
correctly. 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 99358 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99358 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99358 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99358 billed for date of service March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the services provided on March 23, 2023, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a second opinion consultation to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion consultation to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation would not point to a change in status or physical findings that would support the 
medical necessity of a repeat TTE at this time. Clinical guidelines do not support repeating a TTE with no 
intervening change in clinical status or new signs, symptoms or physical findings. There is no supportive evidence for the medical necessity of repeat TTE in this enrollees clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heavy metal testing of zinc assay (84630) provided April 
13, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please review the attached documentation in 
support of the units billed. The Plan denied your request. The Plan says the records provided do not support the 
services. 
 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. There is no documentation provided by the provider of any detailed 
medical history, including documentation of occupational and avocational exposure to these toxins, and records 
do not document a complete physical examination. Based on this information, we decided that Medicare rules 
for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to 
pay for the heavy metal testing of zinc assay (84630) provided April 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee's needs cannot be met at a lower level 
of care. The Plan denied your request. The Plan says the enrollee's records do not show a need for skilled 
nursing services or skilled rehabilitation services on a daily basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided on April 
20, 2023. 
 
You asked the Plan to pay for the infusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare. 
 
We looked at the file and Medicare rules. This service is not covered under Medicare. Based on this 
information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided 
on April 20, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay procedure code G0482 provided on June 8, 2022. 
 
You asked the Plan to pay procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the billing provider and rendering provider 
are not the same. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code G0482 based on Medicare criteria. The claim submitted shows both the rendering 
provider and billing provider identification and the Plan has provided no regulations stating these must be the 
same. Therefore, we decided that the Plan has to pay procedure code G0482 provided on June 8, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 21, 2022, billed 
with codes 81201, 81272, 81292, 81295, 81298, 81307, 81317, 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 21, 2022, billed with codes 81201, 81272, 81292, 81295, 81298, 81307, 81317, 81321 and 81351.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on January 3, 2023, billed 
with codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. 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 iif a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a test 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 testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on January 3, 2023, billed with codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 
87641, 87651, 87798 and U0005.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 25, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed the wrong Place of Service code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 6, 2022, to 
October 5, 2022. 
 You asked the Plan to pay for the home health services. You say that you provided a copy of your billing audit 
report in support of payment. 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 6, 2022. The NOA was not received by the Plan until October 
17, 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 September 6, 2022, to October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on March 22, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77077 billed for date of service February 8, 
2023.  
 You asked the Plan to pay for procedure code 77077. You say that the chart notes show that these services were 
performed on different areas. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code (one with a XE modifier), exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure code 77077 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 77077 billed for date of service February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the silicone breast prothesis (L8030), mastectomy bra 
(L8000), and sales tax (S9999). 
 
You asked the Plan to pay for the silicone breast prothesis, mastectomy bra, and sales tax. You say that the item 
should be covered. The Plan denied your request. The Plan says these items were purchased through a provider 
that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the silicone breast prothesis (L8030), 
mastectomy bra (L8000), and sales tax (S9999).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for a semi-electric hospital bed (E0260). We decided that the Plan does not 
have to pay for DME delivery and set up (A9901).  
 
You asked the Plan to pay for a semi-electric hospital bed and DME delivery and set up. You say that you are 
requesting reconsideration. The Plan says that the billed code is invalid for Medicare purposes. 
 
We decided that the Plan has to pay for a semi-electric hospital bed (E0260).  
 
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 for additional reimbursement for the hospital bed. Specifically, the Plan did not 
gather and/or forward any information regarding their decision to reprocess the claim. The Plan did not explain 
how they reached the increased cost sharing of $199.80. Therefore, we decided that the Plan has to pay for a 
semi-electric hospital bed.  
 
We also decided that the Plan does not have to pay for DME delivery and set up (A9901). 
 
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 A9901 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A9901 is not in the statutory definition of "physician services" for fee schedule payment 
purposes. Based on this information, we decided that Medicare rules for coverage of procedure code A9901 
have not been met. Therefore, we decided that the Plan does not have to pay for DME delivery and set up. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport chair (E1038) purchased on December 12, 2022. 
 
You asked the Plan to pay for a transport chair. You say that the item was medically necessary. The Plan 
denied your request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a transport chair (E1038) purchased on 
December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on December 28, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that the patient arrived in your office due to 
discomfort and was treated accordingly. You say that the treatment was medically necessary. The Plan denied 
your request. The Plan says Medicare generally does not cover routine foot care. There is no documentation of 
any of the specific indications or exceptions under which there are program benefits. 
 
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 podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry 
services provided on December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory (U0003, U0005) service provided March 17, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that you were given incorrect information from 
the nursing facility and had to research and resubmit. The Plan denied your request. The Plan says the claim 
was submitted after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until May 18, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory (U0003, U0005) service provided March 17, 2022.