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

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. 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 July 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 9, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
according to Medicare, an original claim submission must be filed to the appropriate Medicare claims 
processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until August 5, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on  
May 9, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a duplex scan of lower extremity arteries or arterial bypass grafts; 
complete bilateral study. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the documentation does not show any signs or symptoms of intermittent 
claudication, rest pain of vascular disease reduced peripheral blood flow that result in intractable skin ulcers, 
tissue loss, gangrene, or pre-gangrenous changes which would make this request medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 study. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a history of congestive heart failure and peripheral vascular disease is possible and 
needs to be evaluated prior to interventional procedure for the varicose veins. The enrollee currently has 
redness and swelling of the left lower extremity. The presence of arterial vascular disease concomitant with the 
known venous disease is possible especially with the known congestive heart failure needs to be excluded prior 
to interventional therapy for venous disease. 
 
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 study have been met. Therefore, we decided that the Plan has to pre-approve 
a duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study.  
 
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 September 
15, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this should be paid for. 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 cannot be paid when the MAI value is 2.   
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. 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 September 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the rehabilitation to recover from a hip 
fracture.  The Plan denied your request. The Plan says based on Medicare guidelines the inpatient rehabilitation 
facility services you are requesting do not meet the requirements for approval. 
 
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 you are medically stable and do not need physical medicine and rehabilitation 
physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations or chronic medical conditions. No rehabilitation nursing needs are identified or 
documented. At the current functional level, you will not make a significant functional progress in a reasonable 
period of time in an IRF. You do not show that you need 3 hours a day x 5 days a week of therapies with 
multidisciplinary approach in an IRF.  While you would benefit from physical and occupational therapy, your 
rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 
facility. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you need this benefit. The Plan denied your request. 
The Plan says the provided documentation does not show that the three needed criteria are met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI have been met. Medical 
records were not provided with this case. The record shows that the Plan made multiple attempts to obtain this 
information, but it was not received. Without medical records we are unable to determine if you meet the 
criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental 
benefits for the chronically ill (SSBCI).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service  
May 29, 2022. 
 
You asked the Plan to pay for procedure code 99284. The Plan denied your request. The Plan says payment for 
code 99284 is bundled into payment for code 99218. 
 
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 99284 
is a column II code to column I code 99218 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99284 billed for date of service May 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that this service is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve cataract 
surgery to be provided 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 dental services (D0140 and D0367) on June 29, 2022. 
 
You asked the Plan to pay for the dental services (D0140 and D0367). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the requested 
service (D0140) has already been exhausted. The service (D0367) is not covered under the member's contract 
under any normal circumstances. 
 
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, certain limitations apply. The record 
shows your benefit for the requested service (D0140) was exhausted on date of service June 23, 2022. Therefore, we decided that the Plan does not have to pay for the dental services (D0140 and D0367) on June 
29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 88342. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 88342 is bundled into payment for 
code 88189. 
 
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 88342 
is a column II code to column I code 88189. 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 88342 billed for date of service April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planning (D4342) and the delivery of 
antimicrobial agents (D4381) for tooth #18 provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the denied dental services should be covered. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
scaling and root planning and the delivery of antimicrobial agents are not covered by the Plan. 
 
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 pay for the 
scaling and root planning (D4342) and the delivery of antimicrobial agents (D4381) for tooth #18 provided on 
January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary for 
your condition. The Plan denied your request. The Plan says this device is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for a nasal mask cushion. We decided that the Plan does not have to waive the cost share fora nasal mask cushion, nasal application device, and durable medical equipment, miscellaneous for oxygen delivery devices.

You asked the Plan to waive the cost share for cushion for use on the nasal mask, nasal application device, and durable medical equipment, miscellaneous for oxygen delivery devices provided on June 1, 2022. You say that you feel the summary you have received is not accurate. The Plan says that this cost sharing was charged correctly.

We decided that the Plan has to reduce the cost share for a nasal mask cushion.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a 20% coinsurance for durable medical equipment and related supplies.

The Plan says you must pay a 50% coinsurance, or $58.98 ($117.96 allowed amount x 50% = $58.98) for a nasal mask cushion. Based on the Plan contract, however, you cannot be asked to pay more than a 20% coinsurance, or $23.59 ($117.96 allowed amount x 20% = $23.59) for durable medical equipment and related supplies. Therefore, we decided that the Plan has to reduce the cost share for cushion for use on nasal mask.

We also decided that the Plan does not have to waive the cost share for a nasal mask cushion, nasal application device, and durable medical equipment, miscellaneous for oxygen delivery devices.

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 20% coinsurance durable medical equipment and related supplies.

You have been asked to pay a 20% coinsurance for a nasal mask cushion ($117.96 allowed amount x 20% = $23.59), nasal application device ($59.13 allowed amount x 20% = $11.83), and durable medical equipment, miscellaneous for oxygen delivery devices ($2.85 allowed amount x 20% = $0.57). These items fall within the durable medical equipment and related supplies 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 cost share for a nasal mask, nasal application device, and durable medical equipment, miscellaneous for oxygen delivery devices.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
December 20, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  

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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this enrollee does not 
meet the criteria for December 20, 2022, forward as this enrollee was not shown to be a danger to their self or 
others, delusions, auditory or visual hallucinations noted. The enrollee was cooperative/compliant with 
treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from December 20, 2022, 
forward.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on June 22, 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 Original Medicare would be responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 29, 2022, billed with 
codes 81162, 81321, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that the documentation supports the claim as 
billed. 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 
March 29, 2022, billed with codes 81162, 81321, and 81351.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs medicaments dispensed in the office (D9630) and 
gingival irrigation (D4921) provided by a participating provider on July 26, 2022. 
 
You asked the Plan to pay for drugs medicaments dispensed in the office and gingival irrigation. You say that 
this is a financial burden for you. The Plan denied your request. The Plan says the rendered dental services are 
not covered 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 drugs medicaments dispensed in the office (D9630) and gingival irrigation (D4921) provided by a participating 
provider on July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with 
codes  81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. 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 
March 8, 2022, billed with codes  81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 
0032U, 0033U.