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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 18, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head provided on 
February 15, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the enrollee has a 
primary insurance. 
 
  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the CT scan until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for a computed tomography (CT) scan of the head provided on February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
November 6, 2022, to November 9, 2022 
 
You asked the Plan to waive the copayment for a hospital stay. You say that you only had tests done during 
your stay. 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 $150 
copayment per day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay a $150 copayment per day for 3 days of inpatient hospital care ($150 copayment 
per day x 3 days = $450). This item/service 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 provided from November 6, 2022, to 
November 9, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 6, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you did not receive any proper care 
or services from the provider. 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 services provided by a specialist.  
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the services 
provided by a specialist 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 specialist 
office visit provided on November 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the medical records provided support the need for 
the CGM. The Plan denied your request. The Plan says the enrollee does not require insulin three or more times 
daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 23, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the enrollee has a long-standing relationship with 
this provider. 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 provided 
on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on December 6, 
2022, and December 7, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you were inpatient you feel that you 
should not be charged for office visits. 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 $40 
copayment for services obtained from a specialist or nurse practitioner.  
 
You have been asked to pay a $40 copayment for each office visit. You have been asked to pay a total of $80 
($40 copayment x 2 dates of service = $80 copayment). This item/service falls within the services obtained from a specialist or nurse practitioner 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 
office visits provided on December 6, 2022, and December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 8, 2022, billed with 
codes 81194, 81301 and 81455. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 8, 2022, billed with codes 81194, 81301 and 81455.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a multi-axial rotation unit (L5986) and flexible keel foot (L5972). 
 
You asked the Plan to pre-approve a multi-axial rotation unit. You say that the enrollee needs the foot you have 
requested so they can return to the active lifestyle they wish to return to. The Plan denied your request. The 
Plan says that it is not stated that the multi-axial ankle is needed, and this is not supported by the medical 
record provided. 
 
The Plan follows Medicare rules. Medicare rules say that an axial rotation unit (L5982, L5984, L5985, L5986) 
is covered for beneficiaries whose functional level is 2 or above.  
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 a multi-axial rotation unit. Our reviewer 
says that the requested multi-axial rotation unit is medically reasonable and necessary for the enrollee. Our 
physician reviewer found the documentation provided does support that the enrollee has the potential to be at 
least a K2 level ambulator if not K3. The enrollee's residual limb is intact, and they have full strength in the 
lower extremities. Our reviewer found that the enrollee is receiving physical therapy and can use a walker to 
move over 300 feet with their transtibial amputation. The enrollee was noted to be independent with mobility 
and performing daily activities prior to their transtibial amputation. Our physician reviewer also found that the 
requested multi-axial rotation unit (L5986) would be considered medically necessary based on the enrollees 
potential to be at least a K2 if not a K3 level ambulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a multi-axial rotation unit have been met. Therefore, we decided that the Plan 
has to pre-approve a multi-axial rotation unit (L5986) and flexible keel foot (L5972).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this claim denied as a duplicate in error. 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 76642 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 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed with codes 81162, 81201, 81292, 
81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 81408, and 81479 provided on 
August 31, 2022. 
 
You asked the Plan to pay for the panel testing. You say that this testing should be covered. The Plan denied 
your request. The Plan says the testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The test panel is a single test with multiple components. A panel 
cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple 
individual pathogens and/or targets. Based on this information, we decided that Medicare rules for coverage of 
the panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing billed with codes 81162, 81201, 81292, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 
81406, 81407, 81408, and 81479 provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter (K0800). 
 
You asked the Plan to pre-approve a motorized scooter. You say that a scooter is medically necessary. The Plan 
denied your request. The Plan says that the requested scooter is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a motorized scooter (K0800).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for Prolia to be covered, records must show that the 
oral health of the patient was discussed. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found there is no documentation of a discussion of oral health 
prior to the initiation of Prolia therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that this is a covered test which should be paid. 
The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 procedure code 81345 billed for date of service June 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
30, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that the claim was denied for no authorization, 
but there is authorization on file for this date of service. The Plan denied your request. The Plan says procedure 
codes 97530 and 97140 have been overturned. The Plan also says procedure code 97010 is considered bundled 
and not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown-porcelain fused to high 
noble alloys (D6066) for tooth #19 and #30. 
 
You asked the Plan to pre-approve an implant supported crown-porcelain fused to high noble alloys (D6066). 
You say that you are requesting reconsideration for the denial of the dental services. The Plan denied your 
request. The Plan says dental code D6066 is a non-covered code. 
 
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 pre-approve an 
implant supported crown-porcelain fused to high noble alloys (D6066) for tooth #19 and #30.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80061, 82306, 82607, 82728, 82746, 83036, 
83550, 84443) provided on October 12, 2022. 
 You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says screening services are not covered without documentation of a medical 
indication. 
 
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 lab services, 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 
lab services (80061, 82306, 82607, 82728, 82746, 83036, 83550, 84443) provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82044, 82565, and 82570 billed for date of 
service May 20, 2022. 
 
You asked the Plan to pay for procedure codes 82044, 82565, and 82570. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 82044, 82565, and 82570 is 
bundled into payment for codes 82043 and 82575. 
 
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 82044 
is a column II code to column I code 82043. We have confirmed that code 82565 is a column II code to column 
I code 82575. We have confirmed that code 82570 is a column II code to column I code 82575. 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 procedure codes 
82044, 82565, and 82570 billed for date of service May 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan with calcium 
scoring. 
 
You asked the Plan to pre-approve the CT scan. You say that you are seeing a new cardiologist and the test has 
been covered in the past. The Plan denied your request. The Plan says the records do not show the enrollee has 
a cardiovascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan with calcium scoring is not medically necessary. Our physician reviewer found that the current 
evidence showing that the use of coronary artery calcium (CAC) scores in clinical management of 
asymptomatic individuals leads to changes in patient management or in individual risk behaviors that improve 
cardiac outputs outcomes is limited and inconclusive. Overall, there is insufficient support in the peer-reviewed 
literature demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of 
coronary calcium in guiding optimal management of this enrollee. As such, CT imaging of the heart without 
contrast material with quantitative evaluation of coronary calcium is considered experimental/investigational 
for the evaluation and management of this enrollee's medical condition. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan with calcium scoring.