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

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique (87481) and infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified; amplified probe technique, each organism (87798) provided April 22, 2022 
 
You asked the Plan to pay for polymerase chain reaction (PCR) testing. You say that the testing was medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of PCR testing in 
the setting of tinea unguium have not been demonstrated in the peer-reviewed literature. 
 
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 pay for polymerase chain reaction (PCR) testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the medical documentation does not support that this enrollee has 
had their toenail specimen evaluated with potassium hydroxide (KOH) to look for fungal elements, nor has 
their toenail specimen undergone fungal culture. These two laboratory tests are standard of care for the 
evaluation of onychomycosis. They have been proven to be very efficient in demonstrating fungus within a 
toenail. They are also inexpensive, certainly as compared to PCR testing. It appears that the PCR testing 
exceeded this enrollees medical needs and is currently not standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polymerase chain reaction (PCR) testing have not been met. Therefore, we 
decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique (87481) and infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified; amplified probe technique, each organism (87798) provided April 22, 2022
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you need 
more rides available to you. You also say that you only have a power wheelchair and are unable to get to your 
doctor appointments. The Plan denied your request. The Plan says your benefit does not cover more than 50 
one-way trips per plan year and you have utilized all 50 trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 
 trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 12, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the 
copayment. 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 $35 
copayment for physician/practitioner services/in-person specialist visit.  
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/in-person specialist visit 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 specialist office visit provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pre-diagnostic test (D0431), a crown (D2740), core build-
up (D2950), an upper partial denture (D5221), a lower partial denture (D5222), and a removable prosthodontic 
procedure (D5899) provided on September 20, 2021, November 5, 2021, February 16, 2022, and March 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the dental 
services up to your annual dental maximum amount. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because pre-diagnostic tests, crowns, core build-up, partial dentures, and 
removable prosthodontic procedures are not covered by the Plan. 
 
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 a pre-
diagnostic test (D0431), a crown (D2740), core build-up (D2950), an upper partial denture (D5221), a lower 
partial denture (D5222), and a removable prosthodontic procedure (D5899) provided on September 20, 2021, 
November 5, 2021, February 16, 2022, and March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit provided on 
September 12, 2022. 
 
You asked the Plan to waive the copayment for hospital outpatient clinic visit. You say that you should not be 
charged a facility fee, I was not detained for outpatient observation. 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 $300 
copayment for Medicare-covered outpatient hospital services.  
 
You have been asked to pay $115.98, which is less than the standard $300 copayment for hospital outpatient 
clinic visit. This hospital outpatient clinic visit falls within the Outpatient hospital services 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 hospital outpatient clinic visit provided on September 12, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services provided on July 1, 2022, 
to July 30, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis services. You say that you are disputing the share 
cost. 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 20% 
coinsurance for services to treat kidney disease.  
 
You have been asked to pay 20% coinsurance for dialysis services. This item/service falls within the services to 
treat kidney disease 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 dialysis services 
provided on July 1, 2022, to July 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the apicoectomy (D3421). 
 
You asked the Plan to pre-approve the apicoectomy (D3421). You say that insurance is not approving the 
treatment, and you do not have the resources to pay. You say you are in pain and cannot eat due to an infection. 
 The Plan denied your request. The Plan says the service 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 apicoectomy (D3421) is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
apicoectomy (D3421).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed from July 21, 2022, to July 24, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services were not inclusive to the procedure. 
The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99233 was not billed with a modifier to indicate the services were unrelated to the 
surgery services. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99233 billed 
from July 21, 2022, to July 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9945) provided on July 19, 2022. 
 
You asked the Plan to pay for an occlusal guard. You say that you need this guard because you grind your 
teeth. The Plan denied your request. The Plan says the rendered dental service 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 pay for an 
occlusal guard (D9945) provided on July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the beneficiary does not have lymphedema extending 
onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the 
chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. 
 
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 pre-approve a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on November 30, 
2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are disputing the share cost. 
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 $35 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay $35 copayment for specialist visit. This item/service falls within the 
Physician/Practitioner services, including doctor's office visits 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 specialist visit provided on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided on October 4, 2022. 
 
You asked the Plan to pay for a self-administered drug. You say that the member's provider determined the 
drugs were necessary for their health and well-being. The Plan denied your request. The Plan says Medicare 
does not cover self-administered drugs.      
 
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 pay for a self-administered drug 
provided on October 4, 2022.  
 Benefits for a self-administered drug 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on July 14, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 20902 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20902 is bone graft, any donor area; major or large. 
 
We find that CPT code 20902 is not supported in the medical record. Specifically, there is no documentation of 
a major or large bone graft of any donor area. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met.  
 
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 
27640, 27606, and 27641 are column II codes to column I code 27870. The -59 modifier is not supported as a 
separate and distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been 
met. 
 
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network routine cleaning and examination. 
 
You asked the Plan to pre-approve the dental services. You say that you have been seeing this dentist for a long 
time and would like to continue. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits. 
 
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. 
 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve out-of-
network routine cleaning and examination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria for a CGM was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay provided on July 
08, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you shouldnt have to pay 
for this. 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 10% 
coinsurance for Inpatient hospital care. 
 
You have been asked to pay 10% coinsurance for inpatient hospital stay. This item/service falls within the 
Inpatient hospital 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 waive the coinsurance for inpatient 
hospital stay provided on July 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing care provided on August 18, 2022. 
 
You asked the Plan to pay for the initial nursing care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the initial nursing care 
provided on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick Urinary System. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
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 a Purewick Urinary System.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 1, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 1, 2022.