Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on March 15, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you were born with two types of foot deformities and 
walking has become increasingly painful. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on March 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - flexible base (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that your denture was lost in the hospital. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 22, 2022. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture - flexible base 
(D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON outpatient visits. You say that the doctor is not credentialed with 
the hospital. The Plan denied your request. The Plan says the requested services are not unique and can be 
provided 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 
outpatient visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 provided on October 28, 2021. 
 
You asked the Plan to pay for code 64483. 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. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
64483 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 64483 
provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that this accessory is medically 
necessary in addition to the other power wheelchair equipment and accessories. The Plan denied your request. 
The Plan says this accessory is statutorily non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature 
(E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on February 15, 2022. 
 
You asked the Plan to pay for code 83789. 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. 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 the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on February 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional home health care visits. 
 You asked the Plan to pre-approve home health care. You say that the enrollee needs home health due to their 
condition. The Plan denied your request. The Plan says the denial of authorization for 7 additional home health 
visits is correct. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested additional home health care. Our 
physician reviewer found the enrollee does not have documented, ongoing skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 7 additional home health care visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for device evaluation provided on March 22, 
2022. 
 
You asked the Plan to waive the copayment for the device evaluation. You say that you had the device 
unplugged and feel you should not have to pay the copayment. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 each diagnostic X-ray, diagnostic procedure, and testing.  
 
You have been asked to pay a $35 copayment for the device evaluation. The device evaluation falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for device evaluation provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
January 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 
Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator $123.75 $24.75 
Portable Oxygen Machine $22.30 $4.46 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable 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 portable oxygen 
equipment provided on January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) and bone graft at 
time of implant placement (D6104). 
 
You asked the Plan to pre-approve the tissue regeneration and bone graft. The Plan denied your request. The 
Plan says these services are not covered under the enrollees benefit 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 pre-approve 
guided tissue regeneration (D4266) and bone graft at time of implant placement (D6104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee. 
 
You asked the Plan to pre-approve a K3 microprocessor knee. You say that this microprocessor knee is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested 
microprocessor knee exceeds the enrollee's needs. 
 
The Plan follows 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 a K3 microprocessor knee. Our 
reviewer says that the requested microprocessor knee is not medically reasonable and necessary. Our physician 
reviewer found that the microprocessor knee, which is a Blatchford Orion 3 Microprocessor Knee, exceeds the 
patient's medical and functional needs as Medicare does not pay for any items or services that are not 
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. The documentation does not support that the enrollee's activities cannot be safely 
effectively met with a mechanical knee. Furthermore, the Blatchford Orion 3 microprocessor knee has features 
that exceed the patient's needs such as a Cycling Mode and a programming App for Android and iOS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a K3 microprocessor knee have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a K3 microprocessor knee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are out-of-network with the Plan, so no 
precertification was obtained prior to the visit. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider with the Plan. The Plan also says that the referring provider involved in 
these services is a non-participating provider with the Plan. The Plan also says that they did not authorize any 
services for the rendering provider or the facility. 
 
 
 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 laboratory services provided on February 18, 
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, 2021, billed 
with codes 81227, 81230, 81240, 81241, 81291, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. 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 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, 2021, billed with codes 81227, 81230, 81240, 81241, 81291, and 81355.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
February 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 
Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator $123.75 $24.75 
Portable Oxygen Machine $22.30 $4.46 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable 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 portable oxygen 
equipment provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain crown on tooth #4, 6, 7 (D2750), prefabricated 
post/core on tooth #4, 6, 7, endodontic therapy on tooth #4 (D3320), and endodontic therapy on tooth #6 and 7 
(D3310). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot chew food properly and need a 
root canal. The Plan denied your request. The Plan says that the overall maintenance of your teeth is poor. 
 
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. The Plan did not provide adequate dental records that was used in making their 
decision. The Plan did not support their decision to deny your request. Therefore, we decided that the Plan has 
to pre-approve a porcelain crown on tooth #4, 6, 7 (D2750), prefabricated post/core on tooth #4, 6, 7, 
endodontic therapy on tooth #4 (D3320), and endodontic therapy on tooth #6 and 7 (D3310).  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for an angiography of bilateral extremity (75716) billed for date 
of service January 25, 2022. 
 
You asked the Plan to pay for an angiography of bilateral extremity. You say that you have provided medical 
records to support the services at issue. The Plan denied your request. The Plan says rules for payment have not 
been met because the services at issue are included in another billed code. 
 
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 75716 is a column II code to column I code 37228; however, 75716 
was billed with a modifier.  
 
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 an angiography of bilateral extremity. Our reviewer says that 
the services at issue do not meet criteria for reimbursement. Our reviewer found that the procedure report 
describes radiological procedure and intervention in the extremity. In this case, CPT code 75716 would be 
inclusive to the intervention procedure. The available documentation does not support the procedure at issue as 
independent from the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an angiography of bilateral extremity have not been met. Therefore, we decided 
that the Plan does not have to pay for an angiography of bilateral extremity (75716) billed for date of service 
January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 29, 2021, billed with 
codes 81206, 81162, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
should be paid in full. The Plan denied your request. The Plan says this should have been billed with a single 
panel code. Therefore, the Plan has decided to only pay 6 of the 10 line items 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 
July 29, 2021, billed with codes 81206, 81162, 81301, and 81311.
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 your mother is unable to control 
urinating and soiling herself. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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: Favorable

 
We decided that the Plan has to pre-approve the Ossur OP4 knee described by code L5845. 
 
You asked the Plan to pre-approve the knee coded with L5845. You say that this is the correct way to code the 
requested type of knee. The Plan denied your request. The Plan says that this knee is not correctly coded with 
L5845. 
 
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. The Plan has not provided sufficient proof to justify its denial of this code. The 
Ossur OP4 knee has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor and has 
not officially assigned coding. The Plan has failed to provide a specific citation which supports that the use of 
L5845 is not allowed to describe this knee. Therefore, we decided that the Plan has to pre-approve the Ossur 
OP4 knee described by code L5845.  
 
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.