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

 
We decided that the Plan does not have to pay for laboratory services provided on December 19, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says he Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on 
December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis , the ankle foot orthosis, or alcohol wipes 
provided on March 18, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397), and alcohol wipes 
(A4245). You say that these items were medically necessary. The Plan denied your request. The Plan says the 
ankle foot orthosis is still under reasonable useful lifetime, the knee orthosis is not medically necessary, and the 
alcohol wipes should be submitted to Part D. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee had an ankle foot orthosis (L1971) from another provider, when the ankle foot 
orthosis was received from you. The ankle foot orthosis (L1971) serves the same purpose as the ankle foot 
orthosis (L1971) at issue. This orthosis is still within the 5-year RUL and the documentation submitted does 
not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in 
medical condition to warrant the ankle foot orthosis at issue. Based on the records provided, there is no 
indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare 
coverage criteria for orthoses replacement were not met. The alcohol wipes code is not on the physician order 
or invoice. There is no examination documentation of the knee showing joint laxity. Therefore, we decided that 
the Plan does not have to pay for the knee orthosis, ankle foot orthosis, or alcohol wipes provided on March 18, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43235) provided on 
January 28, 2020. 
 
You asked the Plan to pay for an esophagogastroduodenoscopy. You say that this code is supported. The Plan 
denied your request. The Plan says this code should have been billed with modifier 52 to represent reduced 
services. 
 
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 43235 is esophagogastroduodenoscopy, flexible, 
transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate 
procedure). 
 
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 an esophagogastroduodenoscopy. Our 
reviewer says that the records do not support the use of this code. Our physician reviewer found the operative 
report does not include documentation of the scope passing to the second part of the duodenum, and therefore 
cannot not be verified. An appropriate modifier should be billed with this code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an esophagogastroduodenoscopy have not been met. Therefore, we decided that 
the Plan does not have to pay for an esophagogastroduodenoscopy (43235) provided on January 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on February 5, 2020. 
 
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 codes 22853 and 22854 are 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 22853 is insertion of interbody biomechanical device(s) 
(eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), 
when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List 
separately in addition to code for primary procedure). The definition of code 22854 is anterior instrumentation; 
2 to 3 vertebral segments (List separately in addition to code for primary procedure). 
 
We find that CPT codes 22853 and 22854 are not supported in the medical record. Specifically, these are add-
on codes that were 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 the surgical services rendered on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported removable denture. 
 
You asked the Plan to pre-approve the denture. You say that the enrollee has exposed implants, and will not be 
able to eat without dentures that are made to fit around the implants. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's benefit package 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services (D6110 
and D6111) are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve an implant supported removable denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment and implant-supported 
crown for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment and implant-supported crown for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant-supported crown and a custom-fabricated 
abutment for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant-supported crown and a custom-fabricated abutment for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that you want a reconsideration of this denial 
for this authorization. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 93970 provided on April 15, 2020. 
 
You asked the Plan to pay for CPT code 93970. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says CPT code 93970 was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that code 93970 was billed with two or more 
mismatched diagnosis codes. The billed diagnosis codes indicate laterality, which is not appropriate for code 
93970. CPT code 93970 is a bilateral code; therefore, billing diagnosis codes for both sides is not appropriate. 
Therefore, we decided that the Plan does not have to pay for CPT code 93970 provided on April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for power wheelchair, group 2 standard, captains chair, patient 
weight capacity up to and including 300 pounds (CPT Code K0823) purchased on March 2, 2020 from a non-
Medicare provider. 
 
You asked the Plan to pay for the DME. You say that the DME is medically necessary. The Plan denied your 
request. The Plan says you were provided detailed instructions on  how  to obtain the power wheelchair 
(K0823) from an in-network supplier prior to purchase. The Plan states you decided to instead go to a non-
Medicare supplier and purchase the power wheelchair (K0823) out-of-pocket and then submit to the plan for 
consideration of payment. 
 
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 claim denied as Power Wheelchair (K0823) is a capped rental item and is not available for purchase. 
Furthermore, you purchased the wheelchair from a provider who is not certified with Medicare. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. 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 power wheelchair, group 2 standard, captains chair, patient weight capacity up to 
and including 300 pounds (CPT Code K0823) purchased on March 2, 2020 from a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a grab bar. 
 
You asked the Plan to pre-approve a shower chair and a grab bar. You say that you are requesting to reconsider 
the denial for the shower chair and a grab bar. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and grab bars are not covered 
because they are not primarily medical in nature.  
 
While a shower chair and grab bars may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and a 
grab bar.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting (CPT Code 20611) provided on December 10, 2019. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 20611 (1 unit) remains not supported. CPT code 20611represents 
arthrocentesis, aspiration and/or injection, major joint or bursa; with ultrasound guidance, with permanent 
recording and reporting. The submitted documents do not contain documentation of permanently recorded 
images to support the billed charge; therefore, the billed service cannot be verified. It is noted that multiple 
attempts were made to contact the provider for additional information. We have insufficient documentation to 
corroborate the services so we can confirm Medicare coverage has been met. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan 
does not have to pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 
subacromial bursa); with ultrasound guidance, with permanent recording and reporting (CPT Code 20611) 
provided on December 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0428) provided on April 28, 2020. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
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 $210 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
You have been asked to pay a $210 copayment for the one-way Medicare-covered ground ambulance trip 
provided. The Plan contacted the provider and was advised that the original bill issued to you will be adjusted 
to reflect a copayment liability only. 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 ambulance 
transportation service (A0428) provided on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left L3-S1 radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request exceeds the Medicare-allowed number of RFA injections to the lumbar 
region. 
 
The Plan must follow Medicare rules. Medicare rules say that two radiofrequency ablations are covered per 
rolling year.  
 
The records show that RFA sessions were had on 12/5/19 and 12/30/19. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a left L3-S1 radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a MyoPro Motion G Limb orthosis (L8702). 
 
You asked the Plan to pay for the orthosis. You say that the orthosis is necessary and should be covered. The 
Plan denied your request. The Plan says your records show that the requested item has deluxe features that 
exceed medically reasonable and necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not 
covered. The rules also say that experimental and investigational are not covered. The MyoPro Motion G 
orthosis is considered to be experimental and investigational. Therefore, we decided that the Plan does not have 
to pay for a MyoPro Motion G Limb orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided from 
January 5, 2019 to April 5, 2020. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that these claims should not be 
paid by the Plan because this provider is not your oxygen supplier. The Plan denied your request. The Plan says 
the coinsurance amounts you are being charged are correct, because the billed equipment was provided to you 
and was not returned back to the provider. 
 
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 oxygen equipment. For dates of service January 5, 2019 to December 5, 2019, the allowed 
amounts of the claims total $871.56, resulting in a coinsurance amount of $156.71 because this amount ? along 
with other cost-sharing amounts you were asked to pay in 2019 ? met the $3,400 total maximum out-of-pocket 
amount for 2019. For dates of service January 5, 2020 to April 5, 2020, the allowed amounts of the claims total 
$300.80, resulting in a coinsurance amount of $60.16. Your total coinsurance obligation is therefore $216.87. 
 
You have been asked to pay 20% coinsurance for oxygen equipment. Oxygen equipment falls within the 
Durable Medical Equipment (DME) and Related 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 coinsurance for an oxygen concentrator provided from January 5, 2019 to April 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for outpatient physical and occupational 
therapy visits with an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for outpatient physical and occupational therapy visits with an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 12, 2020 by a non-
Medicare provider. 
 
You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the medical services provided on March 12, 2020 by a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty power scooter. 
 
You asked the Plan to pre-approve the heavy duty scooter. You say that a heavy duty scooter should be 
approved because a smaller scooter is not suitable for your living conditions. You say that the scooter that is 
smaller won't move around in the dirt or gravel and will not get out of a pothole if you get stuck and may tip 
over due to the terrain. The Plan denied your request. The Plan says this is correctly denied as you do not meet 
the weight criteria. 
 
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. Coverage for power scooters is based on the enrollee being within the 
weight limit for the scooter. Heavy duty scooters are for enrollees weighing between 285 and 450 pounds. 
 
The documentation shows that you weigh less than 285 pounds. The reasons cited for the need for the heavy 
duty wheelchair involve use outside of the home. Upgrade to the heavy duty scooter solely for use outside the 
home does not meet Medicare coverage criteria.  
 
 Therefore, we decided that the Plan does not have to pre-approve a heavy duty power scooter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the heart. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found CT coronary screening 
for asymptomatic patients is not coverable. No symptoms are described in the physical exam. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the heart.