Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient facility services coded as 72110, 73502, 
82962, 93971, 96372, and 99285 
 
You asked the Plan to pay for the outpatient facility services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT codes 72110, 73502, 82962, 93971, 96372, and 99285 are not supported in the medical 
record. Specifically, the claim was billed without the HCPCS code in line 7 which caused the claim to be 
denied. The appropriate Healthcare Common Procedure Coding System (HCPCS) Code allows for accurate 
payment under Outpatient Prospective Payment System (OPPS) in this situation. Therefore, per the Medicare 
guidelines we find that the Medicare rule for payment of this claim has not been met as the provider did not bill as required by Medicare coding guidelines. Based on this information, we decided that Medicare rules for 
coverage of the outpatient facility services have not been met. Therefore, we decided that the Plan does not 
have to pay for the outpatient facility services coded as 72110, 73502, 82962, 93971, 96372, and 99285
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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 that the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician and nursing oversight in an IRF. Coumadin is therapeutic, 
hemoglobin is stable. The pain is controlled. The acute kidney injury and delirium resolved. While the patient 
may benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires this therapy on an intensive IRF level. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for observation stay provided on March 3, 
2022. 
 
You asked the Plan to waive the copayment for observation stay. You say that you were seen for wound care so 
your copayment should only be $30. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $298 
copayment for observation stay in an outpatient hospital.  
 
You have been asked to pay $112.18 which is less than the standard $298 copayment for observation stay. 
Observation stay falls within the Outpatient Hospital Observation 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 observation stay provided on March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on December 
10, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this care was needed because 
you were mistreated, and these charges should not be charged to you. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
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 $250 
copayment for Medicare-covered surgery or other services at an outpatient or ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges 
 
 You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 outpatient surgery 
provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 9, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the shower chair, with or without wheels, 
any size (E0240) and the standard wheelchair (K0001) purchased on February 4, 2022 and February 5, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items in this case are not 
payable as they were purchased from a provider who is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue reimbursement for the shower chair, with 
or without wheels, any size (E0240) and the standard wheelchair (K0001) purchased on February 4, 2022 and 
February 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back surgery. 
 
You asked the Plan to pre-approve back surgery. You say that you can barely walk and have been in extreme 
pain for two years. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve back surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have back pain. Smoking is a clear contraindication to fusion and results in high fusion 
failure rates. There is no documentation of smoking cessation. Therefore, you do not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of back surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve back surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient cardiac electrophysiology provided on 
December 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient cardiac electrophysiology. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient cardiac electrophysiology provided 
on December 29, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5298) provided on January 24, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid. You say that you would not have gone through with this if you 
had known you would not be reimbursed. The Plan denied your request. The Plan says this service was 
rendered by a provider who is not part of the Plan's vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids when you use the Plan's hearing aid vendor.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not 
have to pay for the hearing aid (V5298) provided on January 24, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an interspinous spacer. 
 
You asked the Plan to pre-approve placement of an interspinous spacer. You say that the requested device is 
medically necessary to treat the enrollee's chronic severe intractable pain. The Plan denied your request. The 
Plan says there is limited long-term data to support the intended result of the requested treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve placement of an interspinous spacer. 
Our reviewer says that placement of an interspinous spacer is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the role of this procedure is still controversial because of 
the high re-operation rate and the lack of long-term follow-up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an interspinous spacer have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of an interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 30, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes on separate claims. Per Medicare rules, the testing should be reported with one unit of one CPT code. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), oral hygiene instructions (D1330) and unspecified preventive procedure, by report (D1999) 
provided March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like these services covered. The Plan 
denied your request. The Plan says your benefit for the comprehensive exam has already been exhausted and 
the remaining services are not covered under your 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. The Plan covers 
comprehensive exams once every three plan years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive exam was exhausted on date of service August 6, 2020. The oral 
hygiene instructions and unspecified preventative procedure are not covered under your benefits. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient 
(D0150), oral hygiene instructions (D1330) and unspecified preventive procedure, by report (D1999) provided 
March 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service February 25, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
with limited field of view  less than one whole jaw (D0380) provided March 21, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. You say that this service should be considered part of 
the root canal. The Plan denied your request. The Plan says this service is not covered under your 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 the cone 
beam computed tomography (CT) image capture with limited field of view  less than one whole jaw (D0380) 
provided March 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 4, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like this denial to be reconsidered. 
The Plan denied your request. The Plan says a prior authorization must be obtained before receiving services 
from a non-participating practitioner or provider. The Plan also says that there is no authorization available for 
the visit on February 04, 2022. 
 
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 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 the medical services provided on February 4, 2022 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the leg for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider did not submit results of an x-ray taken after the tumor or growth appeared 
that showed a need for further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the record indicates 
that the enrollee has calf pain of a few months duration. The enrollee has a hard discolored nodule. The record 
does not indicate any change in size or other worrisome characteristic. The record indicates that only a venous 
duplex was performed. No conservative treatment has been attempted. The requested service is not medically 
necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The 
elements of the coverage criteria are not satisfied. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the leg for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunotherapy services and procedures provided on 
March 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the immunotherapy services and procedures. You say that you would like the 
Plan to pay for your shots from the OON provider. The Plan denied your request. The Plan says the rendering 
provider is OON and there was no approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The 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 the immunotherapy services and procedures 
provided on March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service 
February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology services (88112, 88173, 88305) provided on 
February 8, 2022. 
 
You asked the Plan to pay for cytopathology services. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says rules for payment have not been met 
because the claim at issue is a duplicate of a prior clam that has been processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of cytopathology services have not been met. Specifically, the Plan has documented that the claim at 
issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does 
not have to pay for cytopathology services (88112, 88173, 88305) provided on February 8, 2022.