Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI) coverage. 
 
You asked the Plan to pre-approve SSBCI coverage. You say that you had the benefits available last year. You 
say that your health conditions should qualify you for the requested coverage. The Plan denied your request. 
The Plan says the enrollee has not had 2 or more inpatient admission, or 3 or more emergency room visits in 
the last 60 days. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI coverage. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found that the enrollee is a male with 
diabetes, hypertension, and with an emergency department visit on February 20th for stomach pain and 
constipation. The enrollee followed up the day after at outpatient clinic persistent symptoms but has had 
improvement since the emergency department visit. The provided documentation did not reveal the enrollee 
required intensive care management and did not reveal that the patient has had 2 or more inpatient admissions, or 3 or more emergency room visits in the prior 60 days.  
 
We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI coverage have not been met. Specifically, we have confirmed that you 
do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the 
Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill (SSBCI) coverage.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided on August 4, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you received a letter of approval from the 
Plan for your hip replacement surgery and you were under the impression that all charges would be covered by 
the Plan. You say that you were never informed by the anesthesiologist or the hospital that the anesthesiologist 
was out-of-network, and the charges would not be covered. The Plan denied your request. The Plan says that 
we pay ASA codes to anesthesia providers only. 
 
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 has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Additionally, the Plan has not provided the network status of the facility where 
the approved surgery was performed. Therefore, we decided that the Plan has to pay for anesthesia services 
provided on August 4, 2022.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on June 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says that there are insufficient records to support 
this claim. 
 
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 requested records have since been provided. Therefore, we 
decided that the Plan has to pay for laboratory services provided on June 9, 2022.  
 
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 pay for an office visit (99204) provided on September 28, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that this 
was not a new patient. Based on this information, we decided that Medicare rules for coverage of the office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99204) 
provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
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 did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says the requested supplies are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Russian stimulator. 
 
You asked the Plan to pre-approve a Russian stimulator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Review of the file shows that no recent medical records were 
provided. Without medical records, the documentation does not support the need for the requested device. 
Based on this information, we decided that Medicare rules for coverage of a Russian stimulator have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Russian stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that you feel this item is medically necessary and should be 
covered due to you having cancer. The Plan denied your request. The Plan says the requested item is not a 
covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode chair (E0163) to be delivered to an out-of-
area address. 
 
You asked the Plan to pre-approve a commode chair. You say that you are having hip replacement surgery. 
You say that you will be recovering at your relative's house in another city. You also say that you can pick up 
this item on the day of your surgery. The Plan denied your request. The Plan says the requested item is not 
covered outside of the Plan's service area. 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a commode chair have not been met. Although the records indicate that you reside within the 
Plans coverage area, the requested item is not one that is eligible for pick-up. Additionally, it is not eligible to 
be provided outside of the Plans coverage area. Therefore, we decided that the Plan does not have to pre-
approve a commode chair (E0163) to be delivered to an out-of-area address.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient opioid treatment program billed with code 
G2067 for September 5, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the outpatient opioid treatment 
program billed with code G2067 for September 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on September 14, 2022. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says that the 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 an emergent situation that 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 is not a network provider 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 an injection provided on September 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 6, 2022, to 
October 31, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB 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 home health services rendered from 
October 6, 2022, to October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13101 and 10140 billed for date of service 
July 26, 2022. 
 You asked the Plan to pay for procedure code 13101 and 10140. You say that you disagree with the denial. The 
Plan denied your request. The Plan says payment for codes 13101 and 10140 is bundled into payment for code 
22903. 
 
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 codes 
13101 and 10140 are column II codes to column I code 22903. 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.  
 
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 13102 repair, complex, trunk; each additional 5 cm or 
less (List separately in addition to code for primary procedure). 
 
We find that CPT code 13102 is not supported in the medical record. Specifically, this is an add-on code. 
Given that the primary procedure code 13101 is not separately payable, the add-on code is also not payable. 
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 codes 13101, 13102, and 10140 billed 
for date of service July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service February 16, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on November 15, 
2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says the criteria for coverage of definitive drug testing are not 
met, as the screening results submitted are not inconsistent with the enrollee's prescriptions. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, definitive drug testing is indicated 
when the results of a drug screen are presumptively positive or negative and inconsistent with the enrollees 
medical history.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, the screening results are consistent with the enrollees prescribed medications. Therefore, we decided that the Plan does not have to pay for definitive drug testing 
(G0483) provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for date of service June 25, 
2022. 
 
You asked the Plan to pay for procedure code A4595. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4595 is statutorily excluded from Medicare payment. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4595 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4595 billed for date of service June 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026), ultraviolet therapy (97028), and 
intravenous infusion (96365) provided from August 2, 2022 to August 27, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the infrared therapy, ultraviolet therapy, and intravenous infusion. The Plan 
denied your request. The Plan says the treating provider is not contracted and not covered for alternative 
medicine services by Medicare.  
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 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 infrared therapy (97026), ultraviolet therapy 
(97028), and intravenous infusion (96365) provided from August 2, 2022 to August 27, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 9, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 
81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was 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 
September 9, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81403, 81404, 81405, 81406, 81407, 81408 and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Stabilink MIS interlaminar spinal fixation system 
(22612). 
 
You asked the Plan to pre-approve the Stabilink MIS device. You say that the enrollee completed other surgery 
procedures and is still experiencing extreme pain. Please re-review all clinicals and please approve this 
procedure. The Plan denied your request. The Plan says the Stabilink MIS Interlaminar Spinal Fixation System 
does not meet the requirements for approval. The use of this device as a stand-alone procedure has not been 
shown to be safe and effective in long term studies. 
 
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 pre-approve the Stabilink MIS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Stabilink MIS spinal fixation system is experimental, and more research is 
needed. 
 
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 Stabilink MIS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Stabilink MIS interlaminar spinal fixation system (22612).