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

 
We decided that the Plan does not have to pay for foot orthotics/inserts (L3030) provided on February 4, 2022, 
to February 24, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you need the custom orthotics to help improve your 
walking alignment and balance. You request that these services be reconsidered. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics/inserts (L3030) provided 
on February 4, 2022, to February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on March 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that the Plan's website showed no authorization 
was required for the service rendered and you would like the claim reprocessed for payment. The Plan denied 
your request. The Plan says the rendering provider is an OON provider and there was no referral from an in-
network provider or an 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 surgery services provided on March 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 5, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
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 88341, 88342, 88360, 88381 are not supported in the medical record. Specifically, 
these codes a professional component (PC) / technical component (TC) indicator of 1, meaning that they 
require a TC or 26 modifier. This was not done in this case. 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 the laboratory services provided on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dilation of urethral stricture provided on 
March 9, 2022. 
 
You asked the Plan to waive the copayment for the dilation of urethral stricture. You say that you feel that the 
Plan should cover more of the cost. The Plan denied your request. The Plan says the proper copayment was 
applied for the service that was rendered. 
 
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 $325 
copayment for same-day outpatient surgery in an outpatient hospital facility. The total allowed amount for the 
service provided was $148.27 which is less than the copayment amount of $325. Therefore, only $148.27 was 
charged as the copayment. 
 
  You have been asked to pay a $148.27 copayment for the dilation of urethral stricture. The dilation of urethral 
stricture falls within the Outpatient Hospital Services 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 the dilation of urethral stricture provided on March 9, 2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that this request exceeds your needs. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical conditions appear stable on outpatient medications with no issues that appear to require a physicians evaluation three or more times per week. You 
do require physical therapy and occupational therapy services, but the medical records provided do not clarify 
why you require an intensive inpatient rehabilitation therapy program. Provided records do not explain why the 
intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as 
in a skilled nursing facility is not appropriate for you. There is no documentation that you require the intensive 
medical care and the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
The medical records do not clarify that treatment at the skilled nursing facility level is not appropriate in this 
case. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a standard wheelchair and a pair of 
elevating leg rests provided on March 3, 2022. 
 
You asked the Plan to waive the coinsurance for a standard wheelchair and a pair of elevating leg rests. You 
say that the wheelchair was replaced under warranty. You also say there is no charge to yourself. The Plan 
denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 for Medicare-covered benefits for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay $6.11 in coinsurance, which is 20% of the allowed amount for a standard 
wheelchair and a pair of elevating leg rests ($30.56 allowed amount x 20% coinsurance = $6.11). A standard 
wheelchair and a pair of elevating leg rests fall within the durable medical equipment (DME) 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 coinsurance for a standard wheelchair and 
a pair of elevating leg rests provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardio hereditary genetics test provided to the enrollee on 
February 13, 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 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, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 cardio hereditary genetics test provided to the enrollee on February 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc, Synvisc, or Synvisc-One first. 
 
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 Euflexxa. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces (D2392) and resin-
based composite - three surfaces (D2332) provided on May 17, 2022. 
 
You asked the Plan to pay for the composites. You say that you are low income and do not have the money to 
pay for these services. The Plan denied your request. The Plan says the composites are not a covered service 
under your dental plan. 
 
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 resin-
based composite - two surfaces (D2392) and resin-based composite - three surfaces (D2332) provided on May 
17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97140 billed for date of service January 28, 
2022. 
 
You asked the Plan to pay for procedure code 97140. You say that 29581 and 97140 are billable together. The 
Plan denied your request. The Plan says payment for code 97140 is bundled into payment for code 29581. 
 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 97140 
is a column II code to column I code 29581. 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 97140 billed for date of service January 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 83516, 86038, 86039, 
86146, 86147, 86200, 86225, 86235, 86376, 86431, 86800, 88184, 88185 and 88187 provided on February 17, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting that the denial be 
overturned and the claim reprocessed utilizing the enrollee's in-network benefits for laboratory testing. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 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 coded as 83516, 86038, 
86039, 86146, 86147, 86200, 86225, 86235, 86376, 86431, 86800, 88184, 88185 and 88187 provided on 
February 17, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not have a 
choice deciding which hospital you were going to. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $225 
copayment for each one-way ground ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services 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 
ambulance transportation provided on February 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you received oral medications, had 
stable vital signs and was treated for pain. You were at a standby assist to contact guard level for functional 
mobility including gait to 220 feet with a rolling walker. You do not require skilled nursing or therapy services 
on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing coded as 87799, 87798, 87482 
and 87150 provided March 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review and reprocess the claim 
following the CMS guidance. The Plan denied your request. The Plan says the PCR testing is considered 
unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at 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 the Urine PCR panel testing coded as 87799, 87798, 87482 and 87150 provided March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) billed for date of service 
March 12, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that this service was billed twice because it 
was performed by two different providers for separate issues. The Plan denied your request. The Plan says both 
providers in this case have the same specialty/primary taxonomy. 99233 is a "per diem" code and can only be 
reported once by physicians of the same specialty from the same practice. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that subsequent hospital care codes may only be reported once per day by the same physician or 
physicians of the same specialty from the same group practice. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for billing 
subsequent hospital care have not been met. Specifically, this service was billed twice on the date in question 
by two providers with the same specialty (363LF0000X - Nurse Practitioner Family) from the same group 
practice. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) billed 
for date of service March 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of excessive skin and subcutaneous tissue 
(thighplasty). 
 
You asked the Plan to pre-approve the services. You say that from a plastic surgery standpoint, there could be 
improvement in the contour and skin folds with thighplasty. The Plan denied your request. The Plan says a 
review of the medical literature indicates that thighplasty is a cosmetic or contouring procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our reviewer found that in this case, the record 
indicates that the enrollee had massive weight loss following bariatric surgery. The record provided does not 
demonstrate the presence of intertrigo refractory to conservative medical treatment, the presence of accidental 
injury, or the presence of functional impairment. The elements of the coverage criteria are not satisfied.  The 
requested service is not recommended. 
  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve excision of excessive skin and subcutaneous tissue (thighplasty).