Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93321 billed for September 27, 2020. 
 
You asked the Plan to pay for code 93321. You say that this service was billed appropriately and is supported 
in the record. The Plan denied your request. The Plan says this is an add-on code which was billed without an 
appropriate primary procedure. 
 
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 93321 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 93321 billed for September 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arthroscopy, shoulder, surgical; with rotator cuff repair 
(29827) and Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, 
with coracoacromial ligament (ie, arch) release (29826) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member had a fall and is in need of shoulder 
surgery. The Plan denied your request. The Plan says that records do not show that the enrollee has had a trial 
of conservative management or that advanced imaging has been performed to confirm that the enrollee has soft 
tissue damage. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. The documentation does not indicate that she has tried any conservative measures 
for the right shoulder. Moreover, there are no advanced diagnostic testing (MRI and/or CT) to corroborate rotator cuff pathology. There are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Arthroscopy, shoulder, surgical; with rotator cuff repair (29827) and Arthroscopy, 
shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial 
ligament (ie, arch) release (29826) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 6, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the panel rendered included testing for 
the FANCC gene. This means this entire panel is not covered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 12, 2020, billed 
with codes 81408, 81162, 81321 and 81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 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 
November 12, 2020, billed with codes 81408, 81162, 81321 and 81407.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye surgery provided on May 10, 2022, by an OON provider. 
 
You asked the Plan to pay for the eye surgery. You say that you thought the provider and facility were in-
network. You say that you were not aware there was a prior authorization required. The Plan denied your 
request. The Plan says the out-of-network 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 the eye surgery provided on May 10, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on January 20, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable liquid oxygen system provided on April 4, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a portable liquid oxygen system. You say that you contacted in-network 
suppliers who had nothing similar to what you needed right away. You say that you chose to order from an 
online retailer. The Plan denied your request. The Plan says the out-of-network 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 a portable liquid oxygen system provided on April 
4, 2022, by an OON provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that continued therapies can be given at a lower level of care. 
 
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. 
Clinical documentation shows you have multiple comorbidities but there is no comment on the stability of 
these medical conditions or that close medical supervision on an inpatient basis is required. There are functional impairments documented but there is no documentation to show you require 
interdisciplinary management or intense therapy. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 spinal cord stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the one issue outstanding is the lack of the psychological evaluation. It was reportedly done but there is no documentation submitted. 
Therefore, at this point, the request is considered not medically reasonable or 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77063 and 77067 billed for date of service 
August 17, 2021. 
 You asked the Plan to pay for procedure code 77063 and 77067. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says payment for code 77063 
and 77067 is bundled into payment for code 77066. 
 
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 
77063 and 77067 are both column II codes to column I code 77066. 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 procedure codes 77063 and 77067 billed for 
date of service August 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for gastroesophageal reflux test provided on 
May 4, 2022. 
 
You asked the Plan to waive the copayment for gastroesophageal reflux test. You say that the test was never 
completed so it should be waived. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $295 
copayment for outpatient surgery services.  
 
 
 
 
 
 
 You have been asked to pay $295 copayment for gastroesophageal reflux test. Gastroesophageal reflux test 
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 gastroesophageal reflux test provided on May 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for immunizations and out of network inpatient 
hospital care provided on November 25, 2021, to November 30, 2021. 
 
You asked the Plan to waive the cost share for immunizations and out of network inpatient hospital care. You 
say that you were rushed to the hospital by the fire department and didn't have a choice on where you went. 
You should not be charged out of network. The Plan denied your request. The Plan says the cost share applied 
is correct. 
 
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 $60 
copayment for out of network immunizations and 40% coinsurance for out of network hospital stays.  
 
 You have been asked to pay $5,576.01 copayment for immunizations and out of network inpatient hospital 
care. Immunizations fall within the Immunizations benefit category. Inpatient hospital care 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 cost share for 
immunizations and out of network inpatient hospital care provided on November 25, 2021, to November 30, 
2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from November 7, 2020, to November 
8, 2020, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care as billed with DRG 871. You say that these services were reported 
appropriately, and the diagnoses included on this claim are supported in the medical record. The Plan denied 
your request. The Plan says that the diagnoses of sepsis, unspecified organism (A41.9), severe sepsis without 
septic shock (R65.20) and acute and chronic respiratory failure with hypoxia (J96.21) are not supported in the 
medical records for this inpatient hospital stay. The Plan argues that DRG 194 is more appropriate than DRG 
871 in this case. 
 
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 forward the medical records for this inpatient 
admission. Without these records, we cannot verify that the diagnosis codes billed are not appropriate in this 
case, and the Plan's denial is not substantiated. Therefore, we decided that the Plan has to pay for inpatient 
hospital care provided from November 7, 2020, to November 8, 2020, as billed with Diagnosis Related Group 
(DRG) 871.  
 
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 the magnetic resonance imaging (MRI), spinal canal and contents, 
thoracic; (72146) and MRI, spinal canal and contents, cervical (72141) provided on May 18, 2021. 
 
You asked the Plan to pay for the MRIs. You say that the services should be paid. The Plan denied your 
request. The Plan says that the claim denied correctly. 
 
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 file does not show that the services for this date of service were 
previously paid. Therefore, we decided that the Plan has to pay for the magnetic resonance imaging (MRI), 
spinal canal and contents, thoracic; (72146) and MRI, spinal canal and contents, cervical (72141) provided on 
May 18, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic - porcelain/ceramic (D6245) and retainer crown - 
porcelain/ceramic (D6740) on December 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 December 22, 2021. 
Therefore, we decided that the Plan does not have to pay for pontic - porcelain/ceramic (D6245) and retainer 
crown - porcelain/ceramic (D6740) on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) and guided tissue 
regeneration (D4266) provided on March 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were out of town and cracked a tooth while 
eating. The Plan denied your request. The Plan says a bone replacement graft (D7953) and guided tissue 
regeneration (D4266) are not covered by your routine dental 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. 
 
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 bone 
replacement graft (D7953) and guided tissue regeneration (D4266) provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 21, 
2022, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the treatment was medically 
necessary for the enrollee and the physician provided a statement of medical necessity to justify the reason for 
the stay. The Plan denied your request. The Plan says the out-of-network 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 a domiciliary or rest home visit provided on 
January 21, 2022, by an OON provider.