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

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service July 28, 
2023.  
 
You asked the Plan to pay for procedure code G0481. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code G0481 is bundled into payment for code 80307. 
 
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 G0481 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. 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 G0481 billed for date of service July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ankle foot orthosis (AFO) (L1971) provided on July 5, 
2023. 
 
You asked the Plan to pay for the AFO. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not meet the 
clinical requirements to be approved. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee's medical record must contain sufficient 
documentation of the enrollee's medical condition to substantiate the necessity for the type and quantity of 
items ordered and for the frequency of use or replacement (if applicable). 
 
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 pay for the AFO. Our physician reviewer found that 
the medical information does not include duration of the enrollee's condition, clinical course, prognosis, nature 
and extent of functional limitations, and other therapeutic interventions with their results. Therefore, the 
requested right AFO does not meet the Plan's criteria for dispensing and is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the AFO have not been met. Therefore, we decided that the Plan does not have 
to pay for Ankle foot orthosis (AFO) (L1971) provided on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81305 billed for date of service May 9, 2023. 
 
You asked the Plan to pay for procedure code 81305. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 81305 is bundled into payment for code 81450.  
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 81305 
is a column II code to column I code 81450. 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 81305 billed for date of service May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service July 17, 
2023.  
 
You asked the Plan to pay for procedure code G0482. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code G0482 is bundled into payment for code 80307. 
 
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 G0482 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. 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 G0482 billed for date of service July 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on May 31, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and 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 20% 
coinsurance for Medicare Part B prescription drugs and a $40 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $40 copayment 
for a specialist office visit. The total allowed amount for prescription drugs is $1,438.65. You are being asked 
to pay $287.73 ($1,438.65 x 20% = $287.73). The total amount you are being asked to pay $327.73 ($40 + 
$287.73 =$327.73). This item/service falls within the Medicare Part B prescription drugs and 
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 cost share 
for Medicare Part B prescription drugs and a specialist office visit provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service July 20, 
2023.  
 
You asked the Plan to pay for procedure code G0480. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code G0480 is bundled into payment for code 80307. 
 
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 G0480 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. 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 G0480 billed for date of service July 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 14, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you were able to transport the enrollee to the hospital that was closer. The Plan denied your request. The Plan 
says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 14, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from June 22, 2023, to 
June 29, 2023.  
 
You asked the Plan to reimburse you for psychotherapy. The Plan denied your request. The Plan says proof of 
payment is needed for reimbursement.  
 
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 psychotherapy have been met. Proof of payment was not provided. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from June 22, 2023, to June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a 4-wheel power scooter (E1399) and sales tax 
(S9999) purchased on June 8, 2023. 
 
You asked the Plan to reimburse you for the power scooter. You say that you are on a fixed income. The Plan 
denied your request. The Plan says that the medical records do not indicate a home evaluation was performed. 
The Plan also says that the provider in this case does not participate in Medicare and is not an eligible provider 
of Durable Medical Equipment (DME). 
 
The Plan must follow Medicare rules. Medicare rules say that a POV may be covered when a home evaluation 
which supports that your home has enough room for use of the device was performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power scooter have not been met. Specifically, the records do not include a home evaluation, 
face-to-face encounter for mobility evaluation, nor an order by a treating physician. Therefore, we decided that 
the Plan does not have to reimburse you for a 4-wheel power scooter (E1399) and sales tax (S9999) purchased 
on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 12, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on September 30, 2022, and billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 
87563, 87591, 87641, 87651, 87653, 87661, 87798, and G0452. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says per Local Coverage Article A58726, this type of testing must be 
billed with a single unit of service with a single code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on September 
30, 2022, and billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 
87651, 87653, 87661, 87798, and G0452.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 20, 2023. 
 
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 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 office visit provided 
on July 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is in need of inpatient rehabilitation due 
to weakness and needing physical and occupational therapy in order to regain prior quality of life. The Plan 
denied your request. The Plan says the enrollee is medically stable and without complex rehabilitation needs 
that require a rehabilitation physician to monitor and manage at least 3 times a week in the acute inpatient 
rehabilitation setting. The Plan also says services may be provided at a lower level of care.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spinal surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on July 
25, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. 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 outpatient diagnostic test/x-ray services. 
 
You have been asked to pay a $45 copayment for outpatient diagnostic test. This item/service falls within the 
outpatient diagnostic test/x-ray services 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 outpatient diagnostic test provided on July 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast biopsy provided on May 18, 2023. 
 
You asked the Plan to pay for the breast biopsy. You say that you are requesting reconsideration of 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 the breast biopsy 
provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry care provided on May 3, 2022. 
 
You asked the Plan to pay for podiatry care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
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 podiatry care was not filed until June 5, 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 podiatry care provided on May 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ketamine IV treatment provided from June 6, 2023, to  
June 16, 2023. 
 
You asked the Plan to pay for Ketamine IV treatment. You say that you have major depressive disorder that is 
severe, long term and treatment-resistant. You say that you have been prescribed different depression 
medications and you have tried electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), 
which have not worked for you and your psychiatrist recommended Ketamine IV treatment. The Plan denied 
your request. The Plan says Ketamine IV treatment is experimental. 
 
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 pay for Ketamine IV treatment. Our reviewer says 
that the requested Ketamine IV treatment is not considered medically reasonable and necessary. Our physician reviewer found that based on review the records this procedure is not indicated by the Food and Drug 
Administration (FDA) for the treatment of Depressive Disorders. The use of this procedure of Ketamine 
infusion is considered off label. Based on review of the records provided and the literature provided on the use 
of this procedure, it does not appear that this procedure is considered medically necessary for the treatment of 
depressive disorder and is not considered within the treatment medical necessity due to no FDA indication and 
would be considered experimental/not medically necessary. There is no documentation that you have 
undergone psychotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ketamine IV treatment have not been met. Therefore, we decided that the Plan 
does not have to pay for Ketamine IV treatment provided from June 6, 2023, to June 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 28, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. 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). Although the Plan has a Point-of-Service (POS) option to cover certain out-of-
network services, this benefit only applies to covered routine dental services. Therefore, we decided that the 
Plan does not have to pay for the home visit provided on June 28, 2023.