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

 
We decided that the Plan does not have to pay for procedure code 99292 billed for October 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99292 is not supported. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99292 billed for October 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service December 
22, 2022. 
 You asked the Plan to pay for procedure code 99152. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99152 is bundled into payment for code 45380. 
 
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 99152 
is a column II code to column I code 45380. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 99152 billed for date of service December 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided July 30, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this 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 emergency room services provided July 
30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve an over-bed table. You say that the over-bed table allows you to eat 
comfortably when no one is available to assist you in your home, which is not wheelchair friendly. The Plan 
denied your request. The Plan says the item requested is not primarily medical in nature and excluded by 
Health Plan and Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table (E0274).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an x-ray of the right hand. 
 
You asked the Plan to pre-approve an x-ray of the right hand. You say that your doctor's office submitted a 
referral request to the Plan. The Plan denied your request. The Plan says the x-ray of the right hand was not 
ordered by your provider. X-rays are not part of the services that you can get without first getting approval 
from your provider. 
 
The Plan contract says your PCP, along with the medical group or IPA, provides your medical care. This 
includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital 
admittance. 
 
 
 We looked at the file and the Plans rules. The file shows that the x-ray of the right hand was not ordered by 
your provider. Based on this information, we decided that the Plans rules for coverage of an x-ray of the right 
hand have not been met. Therefore, we decided that the Plan does not have to pre-approve an x-ray of the right 
hand.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal trainer with a wellness center membership. 
 
You asked the Plan to pre-approve a personal trainer with a wellness center membership. You say that the 
services are medically necessary to assist you with performing exercises due to multiple sclerosis. The Plan 
denied your request. The Plan says a personal trainer with a wellness center membership is not a covered 
benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
 The Plans rules for coverage of gym benefits have not been met because a personal trainer is not a covered 
benefit. Therefore, we decided that the Plan does not have to pre-approve a personal trainer with a wellness 
center membership.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on November 14,2022, billed 
with codes 72040, 70100, 70310 74240, 74230, and 92611. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The procedure is a barium swallow study, and 
this means that it involves the administration of a substance to the enrollee. Therefore, we decided that the Plan 
does not have to pay for radiological services provided on November 14,2022, billed with codes 72040, 70100, 
70310 74240, 74230, and 92611.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided on October 21, 2020 to January 
1, 2021. 
 
You asked the Plan to pay for the inpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 inpatient services have been met. 
No medical records were provided to support the services billed. The claim was submitted with an invalid type 
of bill. Therefore, we decided that the Plan does not have to pay for inpatient services provided on October 21, 
2020 to January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 24, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 10, 2022, billed with 
codes 81265 and 81266. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that 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 
March 10, 2022, billed with codes 81265 and 81266.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on March 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is supported 
in the medical record. 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 (0037U) provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. 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 August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance 
(E0673) and pneumatic compression device (E0675) provided on October 27, 2022. 
 
You asked the Plan to pay for the segmental gradient pressure pneumatic appliance and pneumatic compression 
device. You say that the durable medical equipment was prescribed and issued to the enrollee for use during 
their surgery. The Plan denied your request. The Plan says the pneumatic compression devices were billed for 
use outside of the home and are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   
Records show that the segmental gradient pressure pneumatic appliance and pneumatic compression device 
was used in a SNF or hospital.  Therefore, we decided that the Plan does not have to pay for the segmental 
gradient pressure pneumatic appliance (E0673) and pneumatic compression device (E0675) provided on 
October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 20, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a naturopath provider on  
August 5, 2022. 
 
You asked the Plan to pay for the office visit provided by a naturopath provider. You say that code 99204 is a 
standard code for an office visit, not an alternative therapy. The Plan denied your request. The Plan says your 
Plan does not cover alternative therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for an office visit provided by a naturopath provider on August 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on March 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the 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 March 18, 2022. A valid NOA was not received by the Plan. 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 the home health services rendered on March 18, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 31, 2022, to April 
29, 2022. 
 You asked the Plan to pay for home health services. You say that these services were medically necessary. 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 March 31, 2022. The NOA was not received by the Plan until August 2, 
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 
on March 31, 2022, to April 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lenalidomide. 
 
You asked the Plan to pre-approve Lenalidomide. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lenalidomide.  Benefits for Lenalidomide may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0326U) provided on November 1, 
2022. 
 
You asked the Plan to pay for Guardant360 testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says 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. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing 
have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (0326U) 
provided on November 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 14, 2021, to 
February 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that a RAP must be submitted for home health 
claims. 
 
We looked at the file and Medicare rules. The file shows that the required RAP was not received within five 
days of the start of care. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered from January 14, 2021, to February 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injections provided from 
December 19, 2021, to September 9, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you were charged more than 
your out-of-pocket maximum and should be reimbursed. 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 2019 contract with the Plan clearly says that you must pay 
20% coinsurance for Medicare Part B drugs. Your 2020 contract with the Plan also clearly says that you must 
pay 20% coinsurance for Medicare Part B drugs. 
 
The records show your 2019 and 2020 out-of-pocket maximums were processed correctly. You have been 
asked to pay 20% coinsurance for each drug injection provided in 2019. Due to meeting your out-of-pocket 
maximum in 2020, you have only been asked to pay up to 20% coinsurance for some of the drug injections 
provided in 2020. These items/services fall within the Medicare Part B 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the drug injections provided from December 19, 2021, to September 
9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genetic testing panel (81178, 81179, 81180, 81181, 
81182, 81184). 
 
You asked the Plan to pre-approve a genetic testing panel. You say that this testing is necessary to help with the 
prognosis and family history. The Plan denied your request. The Plan says the requested tests are 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. The DEX database does not show that this testing has been covered. 
Based on this information, we decided that Medicare rules for coverage of a genetic testing panel have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a genetic testing panel (81178, 81179, 
81180, 81181, 81182, 81184).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the personal care attendant (PCA) services 
provided on November 30, 2022. 
 
You asked the Plan to reimburse you for the PCA services. You say that the current procedural terminology 
(CPT) is T1021. You also say that your bank statement is enclosed. The Plan denied your request. The Plan 
says the custodial care services are not covered.  
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 PCA services have been met. The 
file does not include any documentation to show what services were provided or why they were necessary. 
Therefore, we decided that the Plan does not have to reimburse you for the personal care attendant (PCA) 
services provided on November 30, 2022.