Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair accessory, u-1 sealed lead acid battery 
(E2365) provided on July 11, 2022. 
 
You asked the Plan to pay for a power wheelchair accessory. You say that you disagree with the denial and 
would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says payment was 
made according to the Medicare allowable rate. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power wheelchair accessory have not been met. Specifically, the record indicates that the Plan 
has paid the Medicare allowed amount for this service. A Medicare provider should accept the Medicare 
allowed amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains 
after the Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for a power 
wheelchair accessory, u-1 sealed lead acid battery (E2365) provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99310 provided on June 14, 2022. 
 
You asked the Plan to pay for procedure code 99310. You say that the medical records support the billing of 
code 99310. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99310. 
 
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 99310 is Subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive 
interval history; A comprehensive examination; Medical decision making of high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may 
be unstable or may have developed a significant new problem requiring immediate physician attention. 
Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
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 99310. Our reviewer says that the medical 
records do not support the billing of code 99310. Our reviewer found the medical record includes a wound care 
report, which does not support a comprehensive history and exam. Per CPT guidelines, 2 of 3 key components 
must be met or exceeded. Therefore, this procedure code 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 procedure code 99310 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99310 provided on June 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) administered on October 17, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (20610) provided on the same date. Based on this information, we decided 
that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan does not 
have to pay for the drugs (J3490) administered on October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81209, 81216, 81223, 81241, 81242, 81249, 
81250, 81298, 81305, 81307). 
 
You asked the Plan to pay for genetic testing. You say that the requested testing is medically necessary. The 
Plan denied your request. The Plan says no additional clinical information was submitted despite multiple 
attempts to obtain. There is no documentation of growth defect, cancer, cystic fibrosis, or bleeding disorder. 
The enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
 
 We looked at the file and Medicare rules. The documentation does not support that these tests were ordered by 
a treating physician for use in managing a specific medical condition. These tests have not completed a MolDx 
technical assessment to meet the Medicare criteria for reasonable and necessary. Many of the tests requested 
are excluded from Medicare coverage. These tests are not Medicare covered screening tests. 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 genetic testing (81209, 81216, 81223, 81241, 81242, 81249, 
81250, 81298, 81305, 81307).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete cervical lymphadenectomy provided to the 
enrollee on December 10, 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 records do not support the services 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 38720 is "Cervical lymphadenectomy (complete)." 
 
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 that in this case, the record indicates 
that the enrollee underwent an operative procedure that included removal of level 2 nodes.  The operative note 
does not document the performance of a complete cervical lymphadenectomy. 
 
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 a complete cervical lymphadenectomy provided to the enrollee on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided August 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed code. 
 
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 G0482 is Drug Testing, Definitive, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the record does not show 
15-21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(G0482) provided August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and should be 
covered. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on March 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the provider 
has taken measurements periodically but there is some kind of glitch within the software that does not allow 
them to enter in the data and post the measurement. The Plan denied your request. The Plan says medical 
records do not show a trial and failure of continuous 4 weeks of measurements or conservative therapy. You do 
not meet approval for the requested PCD. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. At least four weeks 
of regular, daily, multiple-hour home usage is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage after careful, in-person fitting, training and supervision 
by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that Remicade is medically necessary. The Plan denied 
your request. The Plan says a trial of Inflectra is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Remicade. Our reviewer says that 
Remicade is not medically necessary. Our physician reviewer found the record indicates that the enrollee had a 
good response to the plan's preferred alternative. The provided records do not indicate that the enrollee has 
tried and failed the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
September 16, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says there is evidence of 
misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain medical records which support medical necessity for the supplies provided in this 
case. The records provided do not mention the use of an electrical stimulator and/or supplies. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on September 
16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided September 9, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the equipment was prescribed by 
the doctor and was issued to the enrollee for use during their surgery. The Plan denied your request. The Plan 
says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on 
October 27, 2022. 
 
You asked the Plan to pay for 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 the services denied correctly as they do not fall 
within your dental benefits. 
 
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 pay for a 2D 
oral/facial photographic image (D0350) provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on March 15, 2022. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused (D0140). You say that the dentist 
does not like to wait to get paid by the Plan. You also say that you simply gave your debit card to the dental 
office desk employee. The Plan denied your request. The Plan says this service is not covered under the benefit 
package. 
 
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 pay for a limited 
oral evaluation - problem focused (D0140) provided on March 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822 and 95927 provided to the enrollee 
on March 2, 2022. 
 
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 records do not support the services 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 the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
CPT 95927: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 
 
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 that the records do not support CPT 
95822, as the patient was neither in a coma or "sleep." Rather, they were sedated, and the CPT code submitted 
would not be applicable. There is another code that could have been used. Additionally, the records do not 
support the use of CPT 95927 in this case. The enrollee was noted to have had short-latency somatosensory 
evoked potential studies (SSEPs) from the peripheral nerves only. This was coded and reimbursed under CPT 
95938. There was no documentation of any additional SSEPs performed or recorded on this date. 
 
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 procedure codes 95822 and 95927 provided to the enrollee on March 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 11, 2022, to September 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were only in the 
hospital for one day, so you do not understand why you are being billed so much. 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 $490 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $490 copayment for inpatient hospital care. 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. The total you owe is $980 (2/days x $490 = $980). Therefore, we decided that the Plan 
does not have to waive the copayment for inpatient hospital care provided on September 11, 2022, to 
September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and debridement in the presence of 
inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry 
and closure (D6081). 
 
You asked the Plan to pre-approve dental code D6081. You say that you need this procedure done so that you 
may have the caps put back on your teeth. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
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 
scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of 
the implant surfaces, without flap entry and closure (D6081).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional OT visits. 
 
You asked the Plan to pre-approve additional OT visits. You say that you still need occupational services. The 
Plan denied your request. The Plan says the additional occupational therapy (OT) visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
  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 additional OT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the member has previously been treated with outpatient therapies and 
should be independent with a home exercise program.  There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional OT visits.
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. The Plan denied your request. The Plan says the enrollee does not 
have complex medical and intensive rehabilitation needs requiring supervision by a rehabilitation physician and 
an intensive and coordinated interdisciplinary team in a resource intensive inpatient hospital environment. 
 
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 he complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.