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

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 25, 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 claim has not been processed by the 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 confirmed 
that an Explanation of Benefits (EOB) has not been received from the primary insurance. As the secondary 
insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6010, A6219) provided on January 
24, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that the items at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
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 a valid physician order for the supplies provided in this case. The document 
provided as a physician order is dated after the date of service at issue in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for wound care supplies (A6010, A6219) provided on January 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 30, 2021, through 
August 6, 2021, at DRG 682. 
 
  You asked the Plan to pay for inpatient services at DRG 682. You say that the medical records and clinical 
presentation of the patient support the original coding of the claim. You say that the removal of the secondary 
diagnosis code is unjustifiable, and the claim should be reinstated as originally billed. The Plan denied your 
request. The Plan says secondary diagnosis code assignment of G93.41 does not qualify for reporting and 
payment of DRG 682 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code G93.41, defined as metabolic 
encephalopathy. 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 inpatient services at DRG 
682. Our reviewer says that the documentation does not support secondary diagnosis code G93.41. Our 
physician reviewer found the documentation was unclear regarding the secondary diagnosis of metabolic 
encephalopathy. The documentation does not support a clear baseline mental status with change from baseline 
unrelated to underlying dementia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from July 30, 2021, through August 6, 2021, at DRG 682.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 4, 2021 by an 
out-of-network (OON) provider. 
 
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 rendered without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization is required for laboratory services. 
 
The file shows that prior authorization was not obtained for the laboratory services at issue. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on December 4, 2021 by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the polarization (V2762), single vision lens (V2100), 
and deluxe frame (V2025) provided on February 3, 2022. You asked the Plan to pay more for the polarization, single vision lens, and deluxe frame. You say that you 
believe you are to be owed a refund. The Plan denied your request. The Plan says this claim was processed and 
paid correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan offers a $200 Benefit toward the purchase and fitting of eyeglasses and pair of lenses once 
per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that this benefit was exhausted while processing 
this claim for the February 3, 2022, date of service, and you are responsible for the remaining discounted 
amount of $138.40. Based on this information, we decided that the Plan's rules for coverage of the polarization, 
single vision lens, and deluxe frame have not been met. Therefore, we decided that the Plan does not have to 
pay more for the polarization (V2762), single vision lens (V2100), and deluxe frame (V2025) provided on 
February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on March 1, 2022. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the available medical records do not discuss the item at issue. Therefore, we decided 
that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 13, 2021 to 
January 27, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 86596 has an OPPS status indicator of Q4 and 
payment is packaged into payment to the facility. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on December 13, 2021 to January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denied service. The 
Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 laboratory services provided on November 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extension entropion repair rendered on June 23, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that photographs must be adequately documented in the 
patients medical records in order to demonstrate medical necessity of the procedure(s) performed. 
 
We looked at the file and Medicare rules. There are no photographs in the submitted records. Therefore, we 
decided that the Plan does not have to pay for the extension entropion repair rendered on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine rendered on February 10, 2022. 
 
You asked the Plan to pay for these services. You say that the vaccine was recommended by your 
granddaughter's physician. The Plan denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the tetanus vaccine rendered on February 10, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient revision of total knee arthroplasty. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the medical necessity of 
this procedure is not established to be the most appropriate next treatment option. 
 
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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee was being treated for knee pain. Detailed documentation is not evident 
regarding evidence of prosthetic failure or infection of the left knee. X-rays are noted to show a well-
positioned, well-aligned revision total knee arthroplasty with femoral and tibial stems; no loosening is evident. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested revision total knee arthroplasty, 
in this case, is not medically reasonable or 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient revision of total knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint (CPT 27906). 
 
You asked the Plan to pre-approve injection procedure for sacroiliac joint. You say that an injection procedure 
for sacroiliac joint is medically necessary. The Plan denied your request. The Plan says an injection procedure 
for sacroiliac joint "does not meet InterQual criteria, Medicare: Procedures Sacroiliac Joint Injections. 
 
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 injection procedure for sacroiliac joint. 
Our reviewer says that an injection procedure for sacroiliac joint is not considered medically reasonable and 
necessary. Our physician reviewer found that there is no physical exam findings to support this diagnosis. 
There is no imaging that supports this diagnosis. The procedure is not medically reasonable or 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 injection procedure for sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint (CPT 27906).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 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 the laboratory services provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76641) provided on July 27, 2021. 
 
You asked the Plan to pay for the breast ultrasound. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this service was previously processed and paid. 
 
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 code 76641-50-26 is not supported in the medical record. Specifically, the documentation 
submitted indicates that the Plan processed and paid one unit of CPT code 76641-50-26. The documentation 
does not support that this service was rendered more than once on the billed date of service. Based on this 
information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. 
Therefore, we decided that the Plan does not have to pay for the breast ultrasound (76641) provided on July 27, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Nodify CDT testing (81599) provided October 22, 2021 
 
You asked the Plan to pay for the laboratory services. You say that you request for reconsideration for coverage 
for the Nodify CDT test for this enrollee and pay the appropriate rate of $649. The Plan denied your request. 
The Plan says the records do not support that the enrollee meets the criteria. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates that the enrollee with the request for Nodify CDT testing for diagnosis solitary pulmonary nodule. There is no mention of how testing will change treatment. The PET 
scan from 10/20/2021 shows no nodule in lung. The CT scan from 10/13/2021 shows new 1cm pulmonary 
nodule. MAYO risk prediction is 5.9%. Per Medicare guidelines coverage appropriate for: Patient is at least 40 
years of age and has a lung nodule of diameter 8 to 30mm, and the pre-test risk of cancer as determined by the 
Mayo risk prediction algorithm is 50% or less. As no nodule noted on PET scan, no indication for testing. The 
review has determined that the items/services at issue in this case are not medically reasonable or 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for Nodify CDT testing (81599) provided October 22, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty (22858, 22857). 
 
You asked the Plan to pre-approve the total disc arthroplasty. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this procedure is 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 the total disc arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 total disc arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total disc arthroplasty (22858, 22857).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services rendered from March 17, 2020 to 
March 23, 2020. 
 
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 are not covered. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. The file shows that the services were not performed by a qualified 
physician. Based on this information, we decided that the rules for coverage of the acupuncture services have 
not been met. Therefore, we decided that the Plan does not have to pay for the acupuncture services rendered 
from March 17, 2020 to March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection (TFESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says no more than two TFESIs may be performed at a single setting. 
 
The Plan must follow Medicare rules. The rules say that regardless of the number of levels, no more than 2 
TFESIs should be performed at a single setting. 
 
We looked at the file and Medicare rules. The requested TFESI is for a third injection in a single setting. 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 pre-approve a transforaminal epidural steroid injection 
(TFESI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37785 provided on September 27, 2021. 
 
You asked the Plan to pay for procedure code 37785. You say that the medical records illustrate the need of the 
services that were rendered during the inpatient stay. You say that the attached documentation for treatment 
should be reviewed, and payment issued on the claim. The Plan denied your request. The Plan says the 
submitted records do not show evidence of 37785 being performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 37785 have been met. 
Specifically, medical records for the ligation, division or excision of varicose vein cluster (37785) were not 
submitted. Therefore, we decided that the Plan does not have to pay for procedure code 37785 provided on 
September 27, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head/brain (70496) 
provided on April 14, 2022. 
 
You asked the Plan to pay for the CT. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code 70460 is inclusive to 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 70460 
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 the computed tomography (CT) of the head/brain (70496) 
provided on April 14, 2022.