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

 
We decided that the Plan does not have to pay for procedure code 32554 billed for date of service June 15, 
2021. 
 
You asked the Plan to pay for code 32554. You say that this service was reported correctly and is supported in 
the medical record. The Plan denied your request. The Plan says this service is not supported 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, the CPT Code Manual definition of code 32554 is thoracentesis, needle or catheter, aspiration of 
the pleural space; without imaging guidance. 
 
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 code 32554. Our reviewer says that this service is not 
supported in the medical record provided. Our reviewer found the procedure report does not include 
documentation of thoracentesis, aspiration of pleural space, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 32554 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 32554 billed for date of service June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the over-the-counter (OTC) coronavirus test kits 
purchased on April 11, 2022. 
 
You asked the Plan to reimburse you for the OTC test kits. You say that you purchased coronavirus test kits to 
use to get back into the United States while traveling. You say that the website used to purchase these tests 
advised they would be covered. You say that these test kits cannot be purchased in stores. You also say that 
you believed these would be covered. The Plan denied your request. The Plan says the OTC coronavirus test 
kits are not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for over-the-counter 
(OTC) items and the OTC test kit is an OTC item. Therefore, we decided that the Plan does not have to 
reimburse you for the over-the-counter (OTC) coronavirus test kits purchased on April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on January 5, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the procedure 
code is not covered by Medicare. 
 
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 A9270 is non-covered item or service. We find that CPT 
code A9270 is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
supplies provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ neoplasm, 
DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene 
rearrangements, microsatellite instability and tumor mutational burden (CPT code 0037U) provided on March 
16, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim 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 laboratory testing have not been met. The claim did not include 
all the documentation to process the claim. The required DEX Z-Code was not provided. Per LCD L35025, is 
applicable as per Box (32 for electronic box, Box 11 if 32 is empty, if paper Box 32 only) shows the lab was 
rendered in North Carolina. This LCD clearly shows that all tests billed within this jurisdiction are required to 
be billed with a unique test identifier. No unique test identifier issued by MolDx is billed on the claim. 
Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden (CPT code 0037U) provided on 
March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot insert, removable, molded to patient model, 'ucb' 
type, berkeley shell (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has attempted conservative care, 
including proper/supportive shoe gear, orthopedic taping/strapping, imaging to further evaluate, icing, 
topical vs oral NSAIDs and steroid injection. You also say custom orthotics would be beneficial to enrollee's 
pathology and overall support/stability. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
insert, removable, molded to patient model, 'ucb' type, berkeley shell (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee's son is the one that 
referred the enrollee because the son is an established patient. The Plan denied your request. The Plan says 
there is an in-network provider that can perform the services the enrollee needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the chiropractic services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient behavioral health services. 
 
You asked the Plan to pre-approve the inpatient behavioral health services. The Plan denied your request. The 
Plan says that the enrollee's plan only covers 190-day lifetime limit, and the enrollee has no remaining days 
available. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide evidence showing the enrollee has met the 190-day 
lifetime limit for inpatient mental health services provided in a psychiatric hospital. We asked for this 
information, but it was not provided to us. Without this information we cannot determine that the Plan's 
coverage rules support the denial of payment in this case, or that the enrollee's benefit has been exhausted. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pre-approve inpatient behavioral health services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 25, 
2022, to February 6, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this claim was processed 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 for days 1 to 5 you 
must pay a copayment of $225 per day, per admission, for an inpatient hospital stay. For days 6 to 90, you pay 
$0 per day per admission for an inpatient hospital stay.  
 
 
 
 
 
 You have been asked to pay $1125.00 ($225/day x 5 days=$1125) for an inpatient hospital stay. An inpatient 
hospital stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from January 25, 2022, to February 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for office or other outpatient visit for the evaluation and management of an 
established patient (CPT code 99214) provided on May 16, 2021. 
 
You asked the Plan to pay for the service. You say that there were no beds available for admit so the services 
had to be performed in the emergency room setting. The Plan denied your request. The Plan says that the claim 
was denied as the procedure code/bill type is inconsistent with the place of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We cannot confirm that the Plans denial is valid without the place of service 
(POS) code. Therefore, we decided that the Plan has to pay for office or other outpatient visit for the evaluation 
and management of an established patient (CPT code 99214) provided on May 16, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) and therapeutic 
parenteral drugs, two or more administrations, different medications (D9612). 
 
You asked the Plan to pre-approve dental services. You say that you really need this surgery because you are 
already struggling, and it is medically necessary. The Plan denied your request. The Plan says the requested 
services are not covered under your Plan. 
 
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 removal of torus mandibularis (D7473) and 
therapeutic parenteral drugs, two or more administrations, different medications (D9612).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
provided from January 1, 2022, to January 22, 2022. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you expect $0 copay per day for 
days 1-20 and $188 copay for days 21-47. 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). The enrollees contract with the Plan clearly says that enrollees 
$188 copayment for days 21-46. $0 copayment for additional days, up to 100 days. You previously received 29 
days of SNF care from October to December 2021. This SNF stay lasted 21 days, which are days 30 to 50 of 
the SNF benefit period, applying a copayment for 17 days resulting in a copayment of $3196. 
 
The enrollee has been asked to pay a $3196 copayment for the SNF services. The SNF service falls within the 
Skilled Nursing Facility Care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the skilled nursing facility (SNF) services provided from January 1, 2022, to January 22, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the endoscopy provided on August 27, 2021. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you contacted the Plan prior to 
agreeing to schedule this to make sure all charges related thereto were covered by the Plan. The Plan denied 
your request. The Plan says that you have been charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We requested the Plans 2021 Evidence of Coverage (EOC) a total of three 
times. This information is important to our decision to verify that the cost-sharing is correct. Without this 
information the Plan has failed to support their decision. Without the correct EOC they have not shown that the 
cost-sharing applied to this case is appropriate. Therefore, we decided that the Plan has to waive the copayment 
for the endoscopy provided on August 27, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tempus xF testing rendered on October 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the Tempus xF testing is not approved or 
cleared by the Food and Drug Administration (FDA), as required by the Medicare rules. There is no 
documentation that the testing was reasonable or medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus xF testing rendered on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory services provided on February 
16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and laboratory services. You say that you felt it was necessary to 
be seen by someone. You also say that you got an appointment as soon as you could for a diagnosis. You also 
say you were diagnosed and needed to follow a special diet along with an anti-biotic. The Plan denied your 
request. The Plan says you did not receive a referral from your primary care physician (PCP) to see this 
provider. 
 
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 an office visit and laboratory services provided on 
February 16, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses billed for date of services April 5, 2022, to April 
7, 2022. 
 
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the billed supply codes 
cannot be verified. 
 
The Plan must follow Medicare rules. The rules state if the information in the patients medical record does not 
adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved.  
 
We looked at the file and the rules. The records do not include previous physical exams, testing, or imaging to 
confirm a diagnosis or condition. There are no medical records that show a trial of conservative measures. The 
record does not contain relevant medical records which support medical necessity for the supplies provided in 
this case. Therefore, we decided that the Plan does not have to pay for the orthoses billed for date of services 
April 5, 2022, to April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99152, 99153) provided on November 15, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
99152 and 99153 are column II codes to column I code 77300 with a modifier indicator of 0. The column II 
codes are therefore not payable. 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 (99152, 99153) provided on 
November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white fillings for tooth #12 and #18 (CPT code D2393 
x2) and white fillings for tooth #27 (D2332). 
 
You asked the Plan to pre-approve the white fillings. You say that you are in pain and in dire need of these 
dental services. The Plan denied your request. The Plan says the plan maximum provisions and limitations are 
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 Health Plan previously approved coverage for the requested service on July 20, 2022, for two (2) white 
fillings on back of teeth (D2391 x2), and two (2) white fillings for three surfaces on front teeth (D2332 x2). 
The Plan approved a total of four (4) white fillings. The authorization is valid from July 20, 2022, through 
January 16, 2023. Therefore, your request for more than 4 white fillings exceeds your benefit. The Plan 
contract says limitations: four (4) of (D2140-D2394) every calendar year. Therefore, we decided that the Plan 
does not have to pre-approve white fillings for tooth #12 and #18 (CPT code D2393 x2) and white fillings for 
tooth #27 (D2332).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.