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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oasis wound matrix, per sq cm (Q4102), Grafix Core 
and GrafixPL Core, per sq cm (Q4132), and Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq 
cm (Q4133). 
 You asked the Plan to pre-approve Oasis wound matrix, Grafix Core and GrafixPL Core, and Grafix PRIME, 
GrafixPL PRIME, Stravix and StravixPL. 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 wound care is covered when 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 Oasis wound matrix, Grafix Core and 
GrafixPL Core, and Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the medical documentation 
does not indicate that the enrollee has failed attempts at conservative wound therapy. The wound is smaller, 
and it appears that she is ambulating on this foot with a controlled ankle movement (CAM) boot. She also 
continues to smoke. The review has determined that the enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Oasis wound matrix, Grafix Core and GrafixPL Core, and Grafix PRIME, 
GrafixPL PRIME, Stravix and StravixPL have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Oasis wound matrix, per sq cm (Q4102), Grafix Core and GrafixPL Core, per sq cm (Q4132), 
and Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm (Q4133).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 84165 and 84442 provided on December 6, 2021. 
 
You asked the Plan to pay for codes 84165 and 84442. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
We find that CPT codes 84165 and 84442 are not supported in the medical record. Specifically, the 
documentation does not include laboratory results for Protein; electrophoretic fractionation and quantitation, 
serum, code 84165 and Thyroxine binding globulin (TBG), code 84442. Based on this information, we decided 
that Medicare rules for coverage of codes 84165 and 84442 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes 84165 and 84442 provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete dentures (mandibular and maxillary) (D5120, 
D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 Plan's 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 February 22, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete dentures (mandibular and 
maxillary) (D5120, D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on October 12, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy visit 
provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening tests (83036, 80053, 83735, 8443, 85025, 
85610) provided on August 10, 2022. 
 
You asked the Plan to pay for the screening tests. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says these tests are not a Medicare benefit for the diagnoses listed on the claim 
and are done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the screening tests, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the screening tests (83036, 80053, 83735, 8443, 85025, 85610) provided on August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray provided on October 4, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you are providing proof of billing for the 
$30 copayment. 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 up to a 
$30 copayment for an in-network x-ray.  
 
You have been asked to pay a $30 copayment for an x-ray. This item/service falls within the outpatient 
diagnostic testing and 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 a 
chest x-ray provided on October 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an arthrocentesis, a shoulder x-ray, and a 
triamcinlolne injection provided on August 30, 2022. 
 
You asked the Plan to reduce the cost share for an arthrocentesis, x-ray, and an injection. You say that you 
should only be responsible for a $35 specialist copayment. 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 $35 
copayment for in-network services obtained by a specialist, a $15 copayment for an in-network x-ray, and 20% 
coinsurance for in-network Part B drugs. 
 
You have been asked to pay $1.03, which is 20% coinsurance of the allowed amount for an injection ($5.16 
allowed amount x 20% coinsurance = $1.03). This item/service falls within the Medicare Part B prescription 
drugs benefit category.  
 
You have been asked to pay a $35 copayment for specialist services. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $15 copayment for an x-
ray. This item/service falls within the outpatient diagnostic tests and services benefit category. You have been 
asked to pay a total of $51.03 ($1.03 coinsurance + $35 copayment + $15 copayment = $51.03). 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 an arthrocentesis, a shoulder x-ray, and a triamcinlolne injection 
provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic preventive examination (code 99397). 
 
You asked the Plan to pre-approve periodic preventive exam. You say that it is very important to get this 
annual screening done. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that preventive exam code 99397 is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of periodic preventive exam have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a periodic preventive examination (code 99397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - one to three teeth 
per quadrant (D4342). 
 
You asked the Plan to pre-approve the dental services. You say that you have an infection and did not complete 
the deep cleaning. 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 Plan's 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 November 9, 2022. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - one to 
three teeth per quadrant (D4342).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on September 26, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you are disputing the share cost. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab services. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for lab services provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), progressive lenses (V2781), and sales 
tax (S9999) purchased on January 28, 2022. 
 
You asked the Plan to pay for the frames, lenses, and sales tax. You say that you lost your glasses while you 
were in Mexico, and could not wait until your return to the United States to get service. You also say that you 
had no choice but to find the lowest cost optical business for replacement glasses in Mexico. The Plan denied 
your request. The Plan says your plan does not cover care performed outside of the U.S. unless it is an 
emergency. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are provided on an emergency basis, or you go to 
any licensed vision provider in the United States (U.S.). 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you purchased these replacement 
glasses outside of the United State. This purchase was not an emergency. Based on this information, we 
decided that the Plan's rules for coverage of the frames, lenses, and sales tax have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames (V2020), progressive lenses (V2781), and sales tax 
(S9999) purchased on January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 8029959, 8378959, 
80307, and G0483 provided on March 02, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 8029959, 8378959, 80307, and G0483. 
You say that you are appealing the claim payment denial. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes 8029959, 8378959, 80307, and G0483 provided on March 02, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from November 7, 2022, to 
November 9, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you only took what the hospital told you to 
take. The Plan denied your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from November 7, 2022, to November 9, 2022.  
 Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings provided on September 17, 2022, by 
an OON provider. 
 
You asked the Plan to pay for the compression stockings. You say that you are entitled of two pairs of 
compression stockings two times yearly. 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 compression stockings provided on September 17, 
2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot care provided on October 10, 2022. 
 
You asked the Plan to pay for the services. You say that you are dissatisfied that the plan does not cover the 
trimming of lesions or calluses. The Plan denied your request. The Plan says this is routine foot care and not 
covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit 
unless you have diabetic foot disease or some other condition that makes professional care of your feet 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C 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 medically reasonable or necessary. Our physician reviewer found that 
the excision of the hyperkeratotic lesion below this patients fifth metatarsal head should be considered routine 
foot care. The medical documentation does not support that this patient suffers with diabetes, vascular disease 
to the lower extremity, or neuropathy to the lower extremity. The progress note dated 10/10/22 does not 
support that the enrollee has a condition that results in severe loss of circulation or areas of poor sensation in 
the legs/feet. Medicare guidelines advise that Medicare will usually not pay for routine foot care. Therefore, we 
decided that the Plan does not have to pay for foot care provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on August 23, 2022. 
 
You asked the Plan to pay for wound care. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care provided on 
August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on October 03, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you are not happy with your cost 
sharing amount. 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 $350 
copayment for outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for an injection. This item/service falls within the outpatient 
surgery at an outpatient hospital facility 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. However, since the allowed amount is less than the standard copayment, 
you only owe $281.25. Therefore, we decided that the Plan does not have to waive the copayment for an 
injection provided on October 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that the requested wheelchair accessory is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested seat elevation 
system is not covered because they are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87556 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 87556. You say that this testing was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says this service is not supported in the medical 
record. 
 
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 87556 is infectious agent detection by nucleic acid (DNA 
or RNA); Mycobacteria tuberculosis, amplified probe technique. 
 
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 procedure code 87556. Our reviewer says that the records do 
not support CPT code 87556. Our reviewer found the records submitted do not include results for a tuberculosis bacteria test (mycobacteria tuberculosis). It cannot be confirmed that this test was performed 
during the encounter in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87556 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87556 billed for date of service August 24, 2022.