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

 
We decided that the Plan does not have to pay for the assay of triiodothyronine provided on February 24, 2021, 
billed with 84480. 
 
You asked the Plan to pay for the assay of triiodothyronine as billed. You say that this should be paid. The Plan 
denied your request. The Plan says this was billed with a Column 1 code which does not allow a modifier to 
bypass the edit. 
 
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 84480 
is a column II code to column I code 84481.  
 
This edits pair has a modifier indicator of 0 meaning that use of a modifier would still not allow payment. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the assay of triiodothyronine provided on February 24, 2021, billed with 84480.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot x-ray (procedure code 73630) provided to the enrollee 
on August 18, 2021. 
 
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 records do not support the services billed. 
 
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 73630 is Radiologic examination, foot; complete, 
minimum of 3 views." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the notes from 8/18/21 describe the 
radiologic three views of the left ankle, but there is no description of a left foot series. In order to qualify for 
reimbursement, a description of the views of the left foot is required in order to qualify for a separate 
reimbursement.  
We looked at this coder's review, the file, and Medicare rules. 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 pay for a foot x-ray (procedure code 73630) provided to the enrollee on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 20, 2021, to March 21, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the Plan did 
not receive the initial RAP claim within 5 calendar days from the start of care. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from February 20, 2021, to 
March 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and two resin-based 
composites (D2331 x2) provided on October 21, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and 
resin-based composites. You say that you passed out at home and broke two top teeth. You also say that you 
went about a week or week and a half later to have your teeth fixed. The Plan denied your request. The Plan 
says these services are not covered benefits under your dental plan. The Plan also says that you were not 
enrolled in the optional dental rider on this date of service, and those additional benefits are not available to 
you for this date of service. 
 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 pay for the 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional 
intraoral periapical x-ray (D0230), and two resin-based composites (D2331 x2) provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chair portion of a lift chair and sales tax received on 
November 13, 2021. 
 
You asked the Plan to pay for the services. You say that you would like reimbursement. The Plan denied your 
request. The Plan says the plan only covers medically necessary equipment. 
 
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 pay for the chair portion of a lift chair and sales tax received on 
November 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of hospital discharge day management 
services (procedure code 99238) provided to the enrollee on May 23, 2021. 
 
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 one hospital discharge is allowed per stay. 
 
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 99238 is "Hospital discharge day management; 30 
minutes or less." 
 
We find that CPT code 99238 is not supported in the medical record. Specifically, it is not appropriate to bill 
this code twice. Only one discharge service is necessary. 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 pay 
for an additional unit of hospital discharge day management services (procedure code 99238) provided to the 
enrollee on May 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on 
August 19, 2021. 
 
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. 
The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep 
vein thrombosis during and/or following surgery, at home, or in any setting. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. 
 
The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on 
August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 17, 
2021. 
 
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 this service should not unbundled. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on September 17, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexium. 
 
You asked the Plan to pre-approve Nexium. You say that it is your medical opinion that the enrollee should be 
on brand name Nexium. You also say that it is medically necessary due to her history of Barrett's esophagus 
and esophagectomy. The Plan denied your request. The Plan says Nexium is a self-administered drug and does 
not fall under Part B coverage. 
 
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 Nexium.  
 
 
  
Benefits for Nexium 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an additional unit for procedure code 78803 provided to the enrollee on 
August 11, 2021. 
 
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 that there is no additional documentation supporting an additional study, which was billed and 
remains denied. 
 
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 78803 is "Radiopharmaceutical localization of tumor, inflammatory process or distribution of 
radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic 
(SPECT), single area (eg, head, neck, chest, pelvis), single day imaging." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the report of the brain SPECT exam is in 
the submitted records, is well documented and interpreted on 8/11/21. The reason for exam was vascular 
dementia, not tumor localization. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
an additional unit for procedure code 78803 provided to the enrollee on August 11, 2021.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional radiology services provided to the enrollee on August 23, 
2021. 
 
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 that the records submitted do not indicate that two separate services were performed. 
 
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 
the denied codes is: 
 
CPT 70450: 
 
Computed tomography, head or brain; without contrast material 
 
CPT 72125: 
 
Computed tomography, cervical spine; without contrast material 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the computed tomography (CT) of the 
brain and cervical spine studies appear under the same report on 8/28/21. There is documentation of 
appropriate technique and findings under each. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
additional radiology services provided to the enrollee on August 23, 2021.  
 
 
 
 
 
 
 
 
 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: SNF
Decision: Favorable

 
We decided that the Plan has to provide coverage for continued SNF services after March 5, 2022. 
 
You asked the Plan to provide coverage for SNF care. You say that continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says that continuation of SNF care is not medically 
necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before March 5, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to provide coverage for continued SNF services after March 5, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided to the enrollee 
on August 4, 2021. 
 
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 services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for evaluation and management services provided to 
the enrollee on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in network coverage for services related to 
temporomandibular joint dysfunction (TMJ) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve in network coverage for out of network services. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the requested provider is out of 
network. The Plan also says that there are in network providers that can provide these services. 
 
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 
in network coverage for services related to temporomandibular joint dysfunction (TMJ) to be provided by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placements (D6010 x 5), custom fabricated 
abutments (D6057 x 2), and abutment supported crowns (D6058 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that the implants are medically necessary. The 
Plan denied your request. The Plan says the requested dental services are not listed as covered services. 
 
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 implant placements, 
custom fabricated abutments, and abutment supported crowns are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve implant placements (D6010 x 5), custom 
fabricated abutments (D6057 x 2), and abutment supported crowns (D6058 x 5).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory blood test services. 
 You asked the Plan to pre-approve laboratory blood test services. You say that this care is medically necessary. 
The Plan denied your request. The Plan says Original Medicare covers all costs (medicines and services) 
related to a Medicare-approved clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve laboratory blood test services as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve laboratory blood test services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injection (J7273). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested injection is medically necessary. The 
Plan denied your request. The Plan says the requested injection is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Euflexxa. Our reviewer says that the 
requested Euflexxa injection is not medically necessary. Our physician reviewer found the provided x-rays of 
the right knee, which is the side requested for treatment do not indicate the presence of osteoarthritis. The 
reviewer found that the Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested treatment 
is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Specifically, the file does not indicate that the enrollee has osteoarthritis. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injection 
(J7273).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor (E0652) and segmental 
pneumatic appliance (E0668) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the pneumatic compressor (E0652) and segmental pneumatic appliance 
(E0668). You say that this provider is the sole manufacturer and distributor of the prescribed device, and the in-
network device treatment program will not correlate or be equivalent. You say that you disagree with the denial 
as there is no other supplier that is able to provide the same prescribed program. The Plan denied your request. 
The Plan says the service requested is available in-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 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 
the pneumatic compressor (E0652) and segmental pneumatic appliance (E0668) to be provided by an out-of-
network provider.