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

 
We decided that the Plan does not have to pay for  the lipid panel testing provided January 20, 2023. 
 
You asked the Plan to pay for  the laboratory service. You say that you have taken cholesterol medicine for 
some years and the doctor wanted blood tests before they would renew all your prescriptions. 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 that blood tests for the detection 
of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once 
every 5 years (60 months). 
 
In this case, the Plans coverage rules apply. The Plan covers this service once every 5 years. The record shows your benefit for the requested item or service was exhausted on date of service April 5, 2022. This item/service 
falls within the Cardiovascular disease testing 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 pay for  the lipid panel 
testing provided January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service October 31, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. In addition, codes 94761 and 99072 are 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. The rules also 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 procedure code 87631 
have not been met. 
 
In addition, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. We have also confirmed that procedure code 94761 
has a status indicator of T on the Physician Fee Schedule and was billed with other payable services under the 
physician fee schedule for the same date by the same provider. This means that procedure code 94761 is not 
separately payable in this case. Based on this information, we decided that Medicare rules for coverage of 
codes 99072 and 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87631, 94761 and 99072 billed for date of service October 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on January 
27, 2023. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that the doctor ordered this and 
you feel it should be covered. 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 $60 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $60 copayment for the breast ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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 the breast ultrasound provided on January 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Cequa. 
 
You asked the Plan to pre-approve Cequa. You say that the requested drug is a medical necessity for the 
enrollee. 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 drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Cequa.  
 
Benefits for Cequa 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for psychotherapy provided 
from February 7, 2023, to February 21, 2023. 
 
You asked the Plan to reimburse you an additional amount for psychotherapy. You say that reimbursement 
should have been $69.54 per session and the Plan only reimbursed you $57.75. You say the Plan should send 
you the remaining $34.47. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
The allowed amount for this service is $82.50 and 30% of this amount is $24.75. 
 
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 30% 
coinsurance for outpatient mental health care.  
 
You have been asked to pay a 30% coinsurance for psychotherapy. This service falls within the outpatient mental health 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. Therefore, we decided that the Plan does not have to reimburse you an additional amount for 
psychotherapy provided from February 7, 2023, to February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unused over-the-counter benefits. 
 
You asked the Plan to pre-approve the unused over-the-counter benefits. You say that you were unable to 
utilize the OTC benefit for the first quarter and you feel the Plan should grant the benefit back to January 1, 
2023. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC services. However, the Plan offers an OTC benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested items or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
unused over-the-counter benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a  power wheelchair. The Plan denied your request. The Plan says the 
member resides in a SNF. Medicare only covers DME for use in the home. The request was denied as the SNF 
not considered a home. 
 
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 a  power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory polymerase chain reaction (PCR) panel 
provided on February 14, 2022, and billed with codes 87541 and 87798. 
 
You asked the Plan to pay for a respiratory PCR panel. You say that this test should be covered. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of a respiratory PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for a respiratory polymerase chain reaction (PCR) 
panel provided on February 14, 2022, and billed with codes 87541 and 87798.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 23, 2023, billed 
with codes 74230, 72040, 70100, 70310, and 74240. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is 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. This is a barium swallow study and involves 
the injection of a substance into the patient. Therefore, we decided that the Plan does not have to pay for 
radiological services provided on January 23, 2023, billed with codes 74230, 72040, 70100, 70310, and 74240.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (prostate), messenger ribonucleic acid 
(mRNA), microarray gene expression profiling of 22 content genes (81542) and microdissection (i.e., sample 
preparation of microscopically identified target) (88381) provide July 7, 2022. 
 
You asked the Plan to pay for the genetic testing . You say that you are appealing the coverage decision of the 
claim that was submitted for Decipher Prostate genomic testing. The Plan denied your request. The Plan says the services are not supported without the required documentation. the primary carriers Explanation of Benefits 
was not received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has a Group 
Health Plan as primary. As the secondary insurer, the Plan cannot be held responsible for the genetic testing 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for the oncology (prostate), messenger ribonucleic acid (mRNA), microarray gene expression 
profiling of 22 content genes (81542) and microdissection (i.e., sample preparation of microscopically 
identified target) (88381) provide July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99214) provided on September 12, 
2022. 
 
You asked the Plan to pay for a physician office visit. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (27279) provided on June 21, 2022. Based on this information, we decided that 
Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for a physician office visit (99214) provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service February 15, 
2023. 
 
You asked the Plan to pay for procedure code 88305. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules.  
 Medicare rules say that payment is not made under the physician fee schedule for TC services furnished in 
institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and 
outpatient settings. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88305 have not been met. Specifically, procedure code 88305 has a 
professional/technical component indicator of 1. This means that this code has a professional and technical 
component. This code has not been billed with the appropriate modifier to indicate that it is for the professional 
component. Payment for the technical component of this code is included in the payment to the facility and is 
the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for 
procedure code 88305 billed for date of service February 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services rendered from July 26, 2022, to July 28, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The plan has 
contacted the provider to obtain the primary Explanation of Benefits (EOB). After multiple outreaches, this 
information was not received.. As the secondary insurer, the Plan cannot be held responsible for the services 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for hospital services rendered from July 26, 2022, to July 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious-agent testing (87798) provided on January 3, 2023. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that the provided records do not support the service 
billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that the provided records do not clarify the 
infectious agents billed under the unspecified code 87798. We find that the case record contains sufficient 
information, including a testing order and the testing results, to determine the agents billed under code 87798. 
It is the Plan's responsibility to support its denial with evidence. In this case, the Plan's denial is not supported 
by the case record, so we must find in your favor. Therefore, we decided that the Plan has to pay for infectious-
agent testing (87798) provided on January 3, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that this doctor is familiar with your medical history. The Plan denied your request. The Plan 
says care must be obtained from an in-network provider unless care cannot be obtained or is unavailable in the 
Plan's network. Dermatologic care is available within the Plan's 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97164 billed for date of service November 7, 
2022. 
 You asked the Plan to pay for procedure code 97164. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 97164 is bundled into payment for code 97035. 
 
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 97164 
is a column II code to column I code 97035. 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 97164 billed for date of service November 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667). 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the enrollee needs 
to start the compression therapy to reduce and maintain lifetime condition as well as to avoid future infections 
and ulcers. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an 
advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of 
either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pay for a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements. Care may be provided in the current hospital.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.