Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 94761. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 94761 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. These services 
were billed with other services on the same date of service, by the same provider. This means that procedure 
code 94761 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 94761 billed for date of service March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle insertion(s) without injection(s); 1 or 2 muscle(s) 
(20560) provided on November 29, 2022 and December 29, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were not 
rendered on the basis of a covered diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that the rules for 
coverage of the acupuncture services have not been met. Specifically, the acupuncture services provided in this 
case were not rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the 
Plan does not have to pay for the needle insertion(s) without injection(s); 1 or 2 muscle(s) (20560) provided on 
November 29, 2022 and December 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20700, 13132, and 13133 provided on 
November 18, 2021. 
 
You asked the Plan to pay for procedure codes 20700, 13132, and 13133. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows 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 20700 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. 
 
Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not 
covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 
13132 and 13133. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. 
This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid. Based upon this information, we find that Medicare coverage criteria for procedure codes 20700, 13132, 
and 13133 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
20700, 13132, and 13133 provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232-GC) provided from 
November 24, 2022, through November 25, 2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the subsequent hospital care have not been met. For code 99232-
GC (subsequent hospital inpatient or observation care, per day, for the evaluation and management of a 
patient,) was denied because it was reported with a critical care evaluation and management service, 99291 
(Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) 
billed on same date of service by another provider under a different claim. Both physicians have Surgery - 
Surgical Critical Care specialty and billing group. The documentation indicates that the critical care service 
was performed on November 25, 2022. 
 
We are remanding this issue back to the Plan. In this case, the record does not show that the Plan made any 
attempts to obtain a waiver of liability document for the November 24, 2022, date of service. Therefore, we are 
dismissing the November 24, 2022, date of service and referring this issue back to the Plan. The Plan should 
provide the appellant with a waiver of liability form and instructions for completion. Once a valid waiver is 
received, the Plan should complete the plan level review. If the Plan decides it will not pay for the services 
provided, the Plan will send the case back to us as a new appeal. A new case number will be assigned. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232-GC) provided 
from November 24, 2022, through November 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D photographic image (D0350) provided on March 24, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you cannot get your dentures until the bill is 
paid. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
2D photographic image is 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 2D 
photographic image (D0350) provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service March 29, 
2022. You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the service is bundled into another payable service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 96741 was billed on the same day, by the same provider as other payable services. This 
means code 96471 is not separately payable. 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 94761 billed for date of service March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick incontinence system. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee requires this as they are not 
able to get to the bathroom in time during the night. You also say that this is necessary for the enrollee to 
prevent nighttime falls. The Plan denied your request. The Plan says the requested 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 a Purewick incontinence system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader and Sensor continuous 
glucose monitor (CGM). 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Reader and Sensor CGM. You say that your finger is 
sore because you have been poking it twice every day. The CGM will help you monitor your blood sugar level. 
The Plan denied your request. The Plan says you do not require insulin three or more times daily.  
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 use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 Reader and sensor CGM have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Reader and Sensor continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF services provided from May 1, 2022, 
to May 31, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you were not informed that there 
was a copayment when you were first admitted. 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 $0 
copayment for days 1 to 20, a $188 copayment each day for days 21 to 56, and $0 copayment for additional 
Medicaid-covered days, up to 100 days for SNF care.  
 You have been asked to pay a $2,820 copayment for SNF services ($188 copayment per day x 15 days = 
$2,820). This item/service falls within the SNF 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 
copayment for SNF services provided from May 1, 2022, to May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown (D2751) for tooth #18. We decided that the Plan does 
not have to pre-approve the crown (D2751) for tooth #26.  
 You asked the Plan to pre-approve crowns (D2751) for tooth #18 and #26. You say that your teeth are 
sensitive, and the crowns are medically necessary. The Plan says that the teeth do not have 50% bone support; 
therefore, the crowns were denied. 
 
We decided that the Plan has to pre-approve the crown (D2751) for tooth #18.  
 
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. 
 
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 dental services. Our reviewer says 
that the criteria for a crown for tooth #18 was met. Our physician reviewer found the documentation indicates 
that tooth #18 appears to have adequate bone support and significant breakdown of the coronal structure to 
warrant a crown restoration. 
 
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 dental services have been met. Therefore, we decided that the Plan has to 
pre-approve the crown (D2751) for tooth #18.  
 
We also decided that the Plan does not have to pre-approve the crown (D2751) for tooth #26. 
 
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. 
 
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 crown (D2751) for tooth #26. Our 
reviewer says that the criteria for a crown for tooth #26 was not met. Our physician reviewer found the 
documentation indicates tooth #26 does not have adequate bone support and is not a good candidate for long 
term retention.  
 
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 crown (D2751) for tooth #26 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the crown (D2751) for tooth #26. 
 
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 waive the copayment for the esophagogastroduodenoscopy provided 
on December 22, 2022. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that you never had 
to pay for this procedure before. 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 $375 
copayment for in-network outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $375 copayment for the esophagogastroduodenoscopy. This item/service falls within the in-network outpatient surgery, including services provided at ambulatory surgical centers 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 the esophagogastroduodenoscopy provided on 
December 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 1, 2022, to 
January 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was filed timely, so 
this claim should be paid. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 1, 2022, to 
January 26, 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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. All medically necessary care is being provided 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on November 15, 2022. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is not consistent with the procedure. 
 
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 the testing services provided. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee had a family history of AAA, that the enrollee smoked 100 cigarettes in his lifetime or that the enrollee had other established risk factors for 
AAA/cardiovascular disease. As such, the provided screening was not medically necessary or reasonable. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on November 15, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 95999. We decided that the Plan does not have to pay 
for procedure code 95822.  
 
You asked the Plan to pay for procedure codes 95822 and 95999 for date of service April 11, 2022.. You say 
that you disagree with the Plan's denial. The Plan says that the services are not payable as billed. 
 
We decided that the Plan has to pay for procedure code 95999.  
 
The Plan follows 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. Review of the file shows that the Plan states that code 95999 is included in the 
payment of the other services performed on the same date of service, for the same patient, and by the same 
provider and is therefore, not reimbursable. However, the documentation does not show what codes payment 
for this code is included in. No explanation was provided to justify this denial. The Plan did not substantiate 
their denial for code 95999. Therefore, we decided that the Plan has to pay for procedure code 95999.  
 
We also decided that the Plan does not have to pay for procedure code 95822. 
 
The Plan follows Medicare rules. 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 95822 is a column II code to column I code 51785. This claim has not been billed with an 
appropriate modifier to bypass the edit. Therefore, we decided that the Plan does not have to pay for procedure 
code 95822. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (K0899). 
 
You asked the Plan to pre-approve a folding travel scooter. You say that you need the requested scooter to 
safely continue your daily activities. The scooter will ease your chronic back pain. The Plan denied your 
request. The Plan says the requested power scooter has not been assigned a specific code by Medicare and 
therefore is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The requested item is a convenience feature, intended to make 
traveling with this item outside of the home easier. The requested travel scooter has not been assigned a 
specific code by Medicare meaning the item is not reasonable and necessary. Based on this information, we 
decided that Medicare rules for coverage of a folding travel scooter have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power mobility device (K0899).