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

 
We decided that the Plan does not have to pay for the laboratory services provided on August 01, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 August 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the DecisionDx-SCC test (0315U) provided August 4, 2023. 
 You asked the Plan to pay for  the DecisionDx-SCC test. You say that the DecisionDx-SCC test is a covered 
Medicare benefit and should be a covered benefit for the enrollee. The Plan denied your request. The Plan says 
this test is considered experimental and investigational and is not covered. 
 
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. Per DEX Diagnostics Exchange, DecisionDx-SCC is noncovered by 
Medicare. Use of molecular tests such as DecisionDx-SCC are not considered standard of care for determining 
treatment of squamous cell carcinoma. Its use is not supported by National Comprehensive Cancer Network 
(NCCN) Guidelines or the medical literature. In addition, per the Plan's policy Proprietary Laboratory Analyses 
(PLA) Codes, 0315U is listed as a PLA noncovered due to experimental/ investigational status. 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 
August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diabetic shoes and inserts provided on 
August 23, 2023. 
 
You asked the Plan to waive the coinsurance for the diabetic shoes and inserts. You say that you do not agree 
with the co-insurance applied to these items because you get them every year and never had to pay co-
insurance. 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 20% 
coinsurance for diabetes self-management training, diabetic services, and supplies. 
 
You have been asked to pay 20% coinsurance for the diabetic shoes and inserts. This item/service falls within 
the diabetes self-management training, diabetic services, and supplies 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 you owe is $57.36 ($286.78 
allowed amount x 20% = $57.36). Therefore, we decided that the Plan does not have to waive the coinsurance 
for the diabetic shoes and inserts provided on August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
December 2, 2022, and May 8, 2023. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that the services should be 
for annual wellness visits. 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 $45 
copayment for each specialist office visit.  
 You have been asked to pay a $45 copayment for each specialist office visit provided on December 2, 2022, 
and May 8, 2023. These items/services fall within the physician/practitioner services, including doctor's office 
visits benefit category. The total amount you owe is $90 ($45 copayment x 2 visits = $90). 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 specialist office visits provided on December 2, 2022, and May 
8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 8, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 laboratory services have been met. 
In this case, the laboratory order and medical records from the ordering provider were not provided for review. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01992 performed 
on date of service March 27, 2023. 
 
You asked the Plan to pay for 01992. You say that 01992 should be paid as billed because it is supported in the 
medical record and was billed with a valid diagnosis code. The Plan denied your request. The Plan says 01992 
is denied because it was billed without the required modifier -QS, and the diagnosis code assigned does not 
support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that when MAC is provided and procedure code 
01992 is billed, modifier -QS must be used. The rules also say that diagnosis codes M54.16 and M46.1 are not 
listed as diagnosis codes that support medical necessity when billing procedure code 01992.  
We looked at the file and Medicare rules. In this case, the medical records contain evidence that MAC was 
provided. We confirmed that procedure code 01992 was billed without modifier -QS. Modifier -QS is required 
for reporting 01992 when MAC is provided. We have also confirmed that procedure code 01992 was billed 
with diagnosis codes M54.16, defined as radiculopathy, lumbar region, and M46.1, defined as sacroiliitis, not 
elsewhere classified. No additional diagnoses were listed on the claim. Per LCA A57361, M54.16 and M46.1 
do not support medical necessity when billing 01992. As such, the denial of 01992 is appropriate. Based on this 
information, we decided that Medicare rules for coverage of 01992 have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services described by code 01992 performed on date of 
service March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on August 
28, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that this testing was 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 testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on 
August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics (L3020) provided on September 22, 2023. 
 
You asked the Plan to pay for the orthotics (L3020). You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says orthotics are not covered when billed by a 
chiropractor. 
 
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 the orthotics (L3020) provided on September 22, 2023.  
 
Your complaint about a Plan representative informing you that these services would be covered is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for woundfix membrane wrap. 
 
You asked the Plan to pay for woundfix membrane wrap. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says it is not FDA approved for this use and is 
currently not established as the accepted standard of practice within the medical community. 
 
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 woundfix membrane wrap. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee was offered a wound vac, however, the enrollee 
reported the enrollee had a bad experience using a wound vac in the past. The literature has not shown 
woundfix is more effective than standard wound care in the treatment of stage four decubitus ulcer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of woundfix membrane wrap have not been met. Therefore, we decided that the 
Plan does not have to pay for woundfix membrane wrap.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is covered 
by Medicare. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says the records do not show that the services were urgently needed, nor does it 
show that there was a referral provided from an in-network provider for directed care. 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 July 13, 2023, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the electrocardiogram (ECG) and the 
ultrasound on June 21, 2023. 
 
You asked the Plan to waive the copayments for the ECG and the ultrasound. You say that you feel the charges 
are unfair as the procedure was a non-invasive arterial study and non-radiological. 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 $40 
copayment for Medicare-covered non-radiological diagnostic services. You must pay a $150 copayment for 
other Medicare-covered radiological diagnostic services, not including X-rays, performed in a physicians 
office or at a free-standing facility (such as a radiology center or medical clinic). The provider billed in the 
amount of $35 and the allowed amount is $9.24. The provider also billed in the amount of $150 and the 
allowed amount is $61.22. Both are less than the copayment amount. For the service it's $9.24 + $61.22 = 
$70.46. Therefore, results in the total cost sharing amount of $70.46. 
 
You have been asked to pay a $9.24 copayment which less than the copayment for the ECG and a $61.22 
copayment which is less than the copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 electrocardiogram (ECG) and the ultrasound on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 11, 2023, billed 
with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 
87651 and 87653. 
 
You asked the Plan to pay for laboratory services. 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 Current Procedural 
Terminology (CPT) code on the claim. 
 
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 laboratory services provided on September 11, 2023, billed with codes 87500, 
87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on September 
12, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC testing (0315U). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 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. Per review of the DEX Diagnostic Exchange, the DecisionDx-SCC 
test was reviewed through the MolDX process and was found to not meet Medicare coverage criteria. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on 
September 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical dressings and wound care dressings provided on 
September 18, 2023. 
 
You asked the Plan to pay for surgical dressings and wound care dressings. You say that this is a separately 
billable expense and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgical dressings and 
wound care dressings provided on September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased on March 26, 2023. 
 
You asked the Plan to pay for the walker. You say that you couldn't find anyone who carried this specific 
walker.  You said that you were not told that you could not use this provider. The Plan denied your request. 
The Plan says you purchased this item from an online vendor that does not participate with 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 walker you purchased on March 26, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on June 23, 2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare 
program. 
 
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 procedure code A4239 provided on June 
23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Leuprolide injection provided on 
September 26, 2023. 
 
You asked the Plan to waive the coinsurance for a Leuprolide injection. You say that you were not advised that 
a new, much more expensive drug, was being administered. You cannot afford this. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a Leuprolide injection. This item/service falls within the 
Medicare Part B prescription drugs 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 you owe is $826.81 ($4,134.06 x 20% = $826.81). Therefore, we 
decided that the Plan does not have to waive the coinsurance for a Leuprolide injection provided on September 
26, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 28, 2023. 
 
You asked the Plan to pay for the medical services. You say that the codes billed are card out codes for the 
Plan. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 7, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on March 28, 2023.