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

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on October 14, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 20550: 
 
Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") 
 
CPT 76000: 
 
Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time  
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found in terms of CPT 20550, the operative 
report describes that the injection was given for anesthesia, for a tendon sheath incision. This service would be 
inclusive to the primary procedure, as it would be normally performed. The documentation does not support a 
separate injection given. In terms of CPT 7600 and CPT 76942, these procedures would not be covered, as it is 
inclusive to another procedure that was not approved. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on August 13, 2021. 
 
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 the services were 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 services at issue in this appeal.  The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay 
for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered 
by the out-of-network (OON) provider on August 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 24, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 77081 
is a column II code to column I code 77080. 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 imaging services provided to the enrollee on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869) 
procedure. 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested device is experimental. More research is needed to show safety and 
efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869) procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided on August 8, 2021. 
 
You asked the Plan to pay for the inpatient stay. You say that you were originally informed that an 
authorization was not needed due to the length of the patient's stay. The Plan denied your request. The Plan 
says the inpatient stay was not medically necessary. 
 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 pay for the inpatient stay. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found there is no evidence as to when the enrollee was evaluated, what the enrollee was evaluated for, 
what the provider(s) assessed or what the provider(s) planned for care. Our reviewer found that the records 
contain imported historical information and show that radiology staff completed a computed tomography scan. 
Our physician reviewer also found that there is no evidence that a two-midnight, inpatient admission was 
planned or provided. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided on August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular cancer genomic testing provided on August 16, 
2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing is supported in its medical necessity for 
cancer patients. The Plan denied your request. The Plan says the denial of payment for this testing is correct, 
because this test panel constitutes a single procedural service and should have a single procedure code 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that a laboratory panel that procedures multiple 
reportable test results should be billed with a single procedure code.  
 
We looked at the file and Medicare rules. This testing should be billed with a single procedure code. If no 
single code describes the procedure, it may be reported with a miscellaneous or unlisted procedure code with a 
single unit of service. Based on this information, we decided that Medicare rules for coverage of genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for molecular cancer genomic 
testing provided on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has denied correctly based on 
Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling in the presence of moderate or severe gingival 
inflammation (D4346). 
 
You asked the Plan to pre-approve the dental service. You say that you are on a fixed income. You say that you 
need this work completed other work can be done. You also say that there is inflammation around the tooth that 
needs work done. The Plan denied your request. The Plan says scaling in the presence of moderate or severe 
gingival inflammation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested scaling in the presence of 
moderate or severe gingival inflammation is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve scaling in the presence of moderate or severe gingival inflammation 
(D4346).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99284) 
provided on January 8, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for an ER visit. 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 an emergency room (ER) visit (99284) provided on January 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76536) provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $160 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $109.31 copayment for an ultrasound, which is less than the standard $160. 
Ultrasounds fall 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 an ultrasound (76536) provided on November 
8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) to be provided by 
a participating provider. 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you need to get a tooth extracted. 
You say that your current dentures will not fit your mouth. The Plan denied your request. The Plan says the 
benefit limit for D5212 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. The Plan covers a mandibular 
partial denture once every five years.  
 
We looked at the file and Medicare rules. D5212 was previously provided on March 12, 2019. This benefit will 
be exhausted until March 12, 2024. Based on this information, we decided that the Plan's rules for coverage of 
a mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-
approve a mandibular partial denture (D5212) to be provided by a participating provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (T2001). 
 
You asked the Plan to pre-approve transportation services. You say that the enrollee is wheelchair dependent. 
You also say that the enrollee would greatly benefit from medical transportation. The Plan denied your request. 
The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of transportation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve non-emergency transportation (T2001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing 
provided on September 3, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this denial 
is upheld for not meeting Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the cardiac risk assessment genetic 
screening testing provided on September 3, 2021, have been met. Specifically, the record indicates 
contradictions in who ordered the testing service. The Plan has reached out to the provider's office and 
confirmed these services were not ordered for medical necessity and a plan for treatment. The record seems to 
indicate also that the beneficiary self-referred for these services as well. Therefore, we decided that the Plan 
does not have to pay for the cardiac risk assessment genetic screening testing provided on September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on November 17, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is 
included in the payment made to the facility. 
 
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 88305 is not payable when furnished to a hospital 
outpatient. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services 
provided on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Insertion tray with drainage bag with indwelling catheter 
(A4315) provided July 24, 2020. 
 
You asked the Plan to pay for the catheter supplies. You say that this claim denied in error. This claim should 
be processed and paid as the Plan allows 200 units per month. The Plan denied your request. The Plan says 
payment for the previously paid RAP exceeds total due for this episode. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code A4315 is insertion tray with drainage bag with indwelling 
catheter, foley type, two-way, all silicone.  
 
We find that CPT code A4315 is not supported in the medical record. Specifically, the enrollee was receiving 
home health care services from July 8, 2020 to August 6, 2020. All medical supplies are bundled while the 
patient is under a home health plan of care.  This includes, but is not limited to, the above listed medical supplies as well as the Part B items provided in the 
final PPS rule. The Plan had issued payment for the home health care services for July 8, 2020 to August 6, 
2020. Payment for any catheter supplies for this time period was bundled into that payment. Based on this 
information, we decided that Medicare rules for coverage of the catheter supplies have not been met. Therefore, 
we decided that the Plan does not have to pay for Insertion tray with drainage bag with indwelling catheter 
(A4315) provided July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingevectomy (D4212) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a gingevectomy. You say that these services are medically necessary. The 
Plan denied your request. The Plan says D4212 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
gingevectomy (D4212) to be provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy services (45380, 45385, 45381) provided on 
February 23, 2021. 
 
You asked the Plan to pay for the colonoscopy services. You say that additional payment should be provided 
for these services, as they are not bundled procedures. The Plan denied your request. The Plan says these 
services have been paid correctly. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, the codes at issue on this claim have an 
indicator of 3 and the same base endoscopy code.  
 
 
 
 
 
 
 The record clearly indicates that the Plan paid the full value of the highest valued endoscopy, plus the 
difference between the next highest and base endoscopy. Therefore, we decided that the Plan does not have to 
pay for the colonoscopy services (45380, 45385, 45381) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate upper denture (D5130) and lower denture 
reline (D5751). 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the services not 
being covered. The Plan denied your request. The Plan says the requested services are not listed as covered. 
 
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 immediate upper denture 
and lower denture reline are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve an immediate upper denture (D5130) and lower denture reline (D5751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on June 8, 2021. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids must 
be ordered by through the Plan. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through the Plans hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns (D6058 x 3), cone beam CT 
capture with interpretation (D0367), custom abutments (D6057 x 3), facial surgery (D7950 x 3), implant 
placement (D6010 x 3), and provisional implant crowns (D6085 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested services are not listed as covered. 
 
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 abutment supported 
crowns, cone beam CT, custom abutments, facial surgery, implant placement, and provisional implant crowns 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported crowns (D6058 x 3), cone beam CT capture with interpretation (D0367), custom 
abutments (D6057 x 3), facial surgery (D7950 x 3), implant placement (D6010 x 3), and provisional implant 
crowns (D6085 x 3).