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

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery 
only, through separate skin or fascial incision (CPT code 20939). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery 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 pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding a specific indication provided to support the 
request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction 
with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies 
to support the use of bone marrow aspirate for this enrollees medical condition as discussed above. Therefore, 
the requested bone marrow aspirate in the setting of spinal fusion, in this case, is 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or 
fascial incision (CPT code 20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by the out-of-
network (OON) provider on November 9, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the psychotherapy service (90837) rendered by the out-of-network (OON) provider on 
November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5261), provided on September 30, 2021.

You asked the Plan to pay for the hearing aid. You say that the item should be covered. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are received from a provider not part of the plan's hearing aid vendor's network. The hearing benefit is not covered if the services are not registered in advanced.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only obtained through the Plan's hearing vendor and registered in advance.

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Specifically, the hearing aid was purchased out-of-network. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261), provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) provided on January 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is to prevent your regular teeth from falling 
out. You say that it is to prevent teeth from infection. You also say that you do not understand why this is not 
covered as this is important for your preventive care. The Plan denied your request. The Plan says gingival 
irrigation is not listed as a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921 x 2) provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Transitional Care Management Services provided on 
November 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Transitional Care Management Services. You say that you would like to appeal 
the denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 Transitional Care Management Services provided 
on November 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spectrometry testing (83789) provided on June 2, 2021. 
 
You asked the Plan to pay for the spectrometry testing (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 the mass spectrometry testing 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 spectrometry testing (83789) provided on June 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient diagnostic tests provided on 
November 8, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient diagnostic tests. You say that you were told there 
would be no coinsurance. The Plan denied your request. The Plan says the coinsurance was applied 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% of 
the cost for outpatient diagnostic tests.  
 
 
  You have been asked to pay a total of $218.59 for outpatient diagnostic tests. 
 
Service Allowed Amount Standard Cost Member Liability 
Myocardial Perfusion Imaging $74.92 20% $14.98 
Echocardiography $68.09 20% $13.62 
Stress Test W/ECG Monitor $14.08 20% $2.82 
Supervision Only  $21.05 20% $4.21 
Echocardiography (2D) $123.11 20% $24.62 
Myocardial Perfusion Imaging $366.83 20% $73.37 
Injection $238.79 20% $47.76 
Diagnostic Pharmaceutical $162.50 20% $32.50 
Stress Test W/ECG Monitor $23.56 20% $4.71 
TOTAL:   $218.59 
 
 
Outpatient diagnostic tests 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 coinsurance for outpatient diagnostic tests 
provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 
6, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that it is recommended that you receive 
four periodontal maintenance cleanings because of the surgery you had. The Plan denied your request. The 
Plan says this service exceeds the frequency limitation in your benefit 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, periodontal maintenance (D4910) is 
limited to three procedures per plan year. The record shows that you received periodontal maintenance's 
(D4910) on January 20, 2021, April 21, 2021, and August 2, 2021 and your periodontal maintenance (D4910) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for intravenous (IV) infusion services and a 
privigen injection provided on December 3, 2021. 
 
You asked the Plan to reduce the cost share for IV infusion services and an injection. You say that you had the 
same services done in other states and your out-of-pocket expenses were a couple hundred dollars. 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 $350 
copayment for in-network outpatient surgery and other medical services at an outpatient hospital. The Plan 
contract says that enrollees must pay 20% coinsurance for in-network Part B drugs. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $282.09, which is less than the $350 copayment for IV infusion services. IV infusion services fall 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers category.  
 
You have been asked to pay $533.76, which is 20% coinsurance of the allowed amount for a privigen injection 
($2,668.80 allowed amount x 20% coinsurance = $533.76). You have been asked to pay a total of $815.85 
($282.09 copayment + $533.76 coinsurance = $815.85). A privigen injection falls within the Medicare Part B 
Prescription Drug 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 reduce the cost share for intravenous (IV) 
infusion services and a privigen injection provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on October 13, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the services being rendered. 
 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 domiciliary or rest home visit provided on October 
13, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lung cancer panel testing provided on August 18, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
We looked at the file and the rules. We find that CPT code 81479-XU is not supported in the medical record. 
Specifically, the records provided do not indicate an unusual non-overlapping service was provided. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the lung cancer panel testing provided on August 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasonic guidance for needle placement (76942) 
provided on August 7, 2021. 
 
You asked the Plan to pay for code 76942. 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 must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76942 
is a column II code to column I code 36556. 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 the Ultrasonic guidance for needle placement (76942) provided 
on August 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Face mask, filter, and tubing provided on March 23, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Face mask, filter, and tubing. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
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 Face mask, filter, and tubing provided on March 
23, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The patient has 
primary osteoarthritis of the right shoulder with a scheduled total reversal shoulder arthroplasty. This is a 
request for inpatient services related to this procedure. The provided documentation, however, does not reveal 
the patient as unstable or having high risk factors to expect the patient would require inpatient services 
following this typically ambulatory procedure. There is no expectation that the patient will require hospital care 
that would likely cross 2 midnights. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70470) provided on January 3, 2022.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

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 70470 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70470) provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on  
November 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on November 26, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81479) provided on March 15, 2021. 
 
You asked the Plan to pay for code 81479. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for code 81479 by a contract provider. The file does not show that the plan provided 
notice that code 81479 would not be covered. Under Medicare rules, this means code 81479 is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services (81479) 
provided on March 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (S9999) from item purchased September 24, 2021. 
 
You asked the Plan to pay for sales tax. You say that you received this benefit from the Plan the previous year 
(2020). Your insurance did not change, nor did your benefits or health conditions, so this is still a covered 
benefit. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that code S9999 for sales tax is not payable as they are 
included in the cost of DME. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax 
(S9999) from item purchased September 24, 2021.