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

 
We decided that the Plan does not have to pay for code 99285 billed for date of service June 4, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285. 
The Plan denied your request. The Plan says code 99285 is not supported. The medical records don't support a 
high level of medical decision making. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical records. Our reviewer found the enrollee is a 38-year-old patient with a history of 
sickle cell disease who presented to emergency room with concerns she was in sickle cell crisis. Although the 
history, exam, work-up and interventions were comprehensive, the documentation regarding the level of 
medical decision making appears incomplete and there is no interpretation of tests.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service June 4, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service July 18, 
2023.  
 You asked the Plan to pay for procedure code 76642. You say that code 76642 was billed correctly and should 
be paid.  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 76642 is 1 unit. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 24, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that 71045 should be paid as billed because the 
enrollee had multiple exams on the same date of service, and they are supported in the documentation. The 
Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 32555. 
 
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 71045 
is a column II code to column I code 32555. 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 71045 billed for date of service July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 2, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on February 2, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the lab testing and office visit on July 24, 
2023.  
 
You asked the Plan to waive the copayments for the lab testing and office visit. You say that you don't 
understand why you have to pay the extra copays and you believe it should have been free. 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 $0 to 
$10 copayment for lab services. You must pay a $10 copayment for services obtained from a primary care 
provider or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other non-
physician health care professionals in a primary care providers office (as permitted under the Medicare rules). 
The provider billed in the amount of $17 and the allowed amount is $8.57. This is less than the copayment 
amount. For both services it's $8.57 + $10 = $18.57. Therefore, results in the total cost sharing amount of 
$18.57. 
 
You have been asked to pay $8.57 copayment which is less than the copayment for the lab testing and a $10 
copayment for office visit. This item/service falls within the outpatient diagnostic tests and therapeutic services 
and supplies and physician/practitioner services, including doctors office visits 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 copayments for the lab testing and office visit on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chiropractic care provided on June 12, 2023. 
 
You asked the Plan to waive the cost share for chiropractic care . You say that you disagree with the cost share. 
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. Your 
contract with the Plan says that there is a $400 deductible which applies to chiropractic services.  
 
The item or service you asked the Plan to waive the cost share for falls within the chiropractic services benefit 
category. You are being asked to pay $65 towards your deductible. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $400 deductible which applies to chiropractic services. This cost 
sharing is a contractual obligation that had not been met at the time chiropractic care was received on June 12, 
2023. Therefore, we decided that the Plan does not have to waive the cost share for chiropractic care provided 
on June 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar-sacral orthosis to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve lumbar-sacral orthosis. You say that the services should be covered. The 
Plan denied your request. The Plan says this is available in-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 
lumbar-sacral orthosis to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device provided on December 
06, 2022. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the supplies 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 intermittent limb 
compression device provided on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on March 29, 2023. 
 You asked the Plan to pay for the psychotherapy visit. You say that you are seeking review for the submitted 
documents. 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 psychotherapy visit 
provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on July 18, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory service provided on July 18, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
29, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from June 13, 2023, to June 29, 2023. 
 
You asked the Plan to pay for acupuncture. The Plan denied your request. The Plan says the primary diagnosis 
code of M54.50 (Low back pain, unspecified) is not a diagnosis that supports an acupuncture service for lower 
back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the primary diagnosis code of M54.50 
(Low back pain, unspecified) is not a diagnosis that supports an acupuncture service for lower back pain. 
Therefore, we decided that the Plan does not have to pay for acupuncture provided from June 13, 2023, to  
June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on March 04, 2022. 
 
You asked the Plan to pay for physicians services. You say that the 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 physicians services 
provided on March 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 28, 
2023, to July 05, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 inpatient hospital care. 
 
You have been asked to pay a $275 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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 amount you owe is $1,100 ($275 x 4 days = $1,100). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on June 28, 2023, to July 
05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. 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 July 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service and the travel allowance provided on 
March 14, 2023, by an OON provider.  
 
You asked the Plan to pay for the laboratory service and the travel allowance. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory service and the travel allowance 
provided on March 14, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the new patient office visit provided by an 
out-of-network provider on May 23, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you think that the cost sharing 
should be lower. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network podiatry services. 
 
You have been asked to pay a $120.27 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for was provided by an out-of-network provider. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1,000 deductible which applies to out-of-network podiatry 
services. This cost sharing is a contractual obligation that had not been met at the time the office visit was 
received on May 23, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the 
new patient office visit provided by an out-of-network provider on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on June 29, 2023. 
 
You asked the Plan to pay for physicians services. You say that the 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 physicians services 
provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement provided on June 22, 2023. 
 
You asked the Plan to pay for the nail debridement. You say that the provider had to correct the claim because 
they found out the enroll had active coverage. The Plan denied your request. The Plan says the appeal was filed 
untimely, therefore, will deny the payment. 
 
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 nail debridement was not filed until July 25, 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 nail debridement provided on June 22, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 CDx testing (81479) provided on August 6, 2023. 
 
You asked the Plan to pay for Guardant360 CDx testing. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx testing 
have been met. Therefore, we decided that the Plan has to pay for Guardant360 CDx testing (81479) provided 
on August 6, 2023.  
 
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.