Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the procedure. The Plan 
denied your request. The Plan says that the code has an MUE value of 1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, the CPT Code Manual definition of code 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 is supported. 
Code 76641 has an MUE value of 2. The claim shows that 1 unit of service with the RT modifier was billed on 
one line, and 1 unit of service with the LT modifier was billed on the other claim line as required. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code 76641 billed for date of service September 20, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis. 
 
You asked the Plan to pre-approve the MRI. You say that it is medically necessary for the enrollee to get the 
MRI done. The Plan denied your request. The Plan says he Medicare guidelines for the MRI were not met. 
 
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 
MRI of the pelvis is not medically necessary. Our physician reviewer found that the enrollee does not have 
history of prior complex inguinal hernia repair with mesh. The enrollee does not document inguinal hernias on 
physical examination or ultrasound. Request for MRI of the pelvis to evaluate for inguinal hernia is not 
determined to be medically necessary. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the pelvis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 6, 2022, to September 8, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $290 copayment per day for days 1-7 for inpatient hospital care. This 
item/service falls within the inpatient hospital care benefit category. The total amount you are being asked to 
pay $580 ($290 x 2days = $580). 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 inpatient hospital care 
provided on September 6, 2022, to September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010) for tooth #6 and #29. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist says that the dental services 
requested are necessary. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because dental implants and all associated services 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implants (D6010) for tooth #6 and #29.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of 
service January 27, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, and 88360. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility payment and 
are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 88342, 
and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 88341, 
88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 88341, 88342, and 88360 billed for date of service January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650), provided on August 17, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the medical records do not show that the member has back pain, there 
is also no evidence in the medical records that discussed the need for a lumbar-sacral orthosis or the frequency 
for its use. 
 
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 relevant medical records which support medical necessity for the supplies 
provided in this case. The medical records do not show that the member has back pain, there is also no evidence in the medical records that discussed the need for a lumbar-sacral orthosis or the frequency for its use. 
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 the lumbar-sacral orthosis (L0650), provided on 
August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral supplements. 
 
You asked the Plan to pre-approve oral supplements. You say that you need this item. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve oral supplements.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but requires additional short term acute care 
services that can be safely administered at the current facility until more stable and appropriate for a lower 
level of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 6, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you needed to get a second 
exam because you were uncomfortable with the first provider's treatment. The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. 
 
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 item or service was exhausted on date of service June 3, 2022. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that a CGM would be beneficial for the 
enrollee to monitor their daily blood glucose levels. The Plan denied your request. The Plan says that the 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM and supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) guidance for, and monitoring 
of, parenchymal tissue ablation (77013) and ablation (50592) provided on February 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the CT and ablation. You say that you would like this claim to be reviewed and 
reprocessed. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless they are pre-authorized. 
 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 computed tomography (CT) guidance for, and 
monitoring of, parenchymal tissue ablation (77013) and ablation (50592) provided on February 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service May 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple claims on this date of 
service. The Plan denied your request. The Plan says that a duplicate claim has already been considered for 
payment. 
 
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, billed with the LT and RT modifiers, is supported in the medical record. The 
Plan has not provided documentation to show that the claim lines were billed twice for the date of service at 
issue. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request. Based on this information, we decided that Medicare rules for coverage of 
the billed services have been met. Therefore, we decided that the Plan has to pay for procedure code 76641 
billed for date of service May 16, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit, and intravenous 
infusions provided from January 20, 2022, to January 22, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit and intravenous infusions. You say 
that you were informed these charges are to be covered in full. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 for 
each emergency room visit. Your contract with the Plan also clearly says that you must pay $370 for outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 
 
 
 You have been asked to pay $90 for an emergency room visit on January 20, 2022. This item/services falls 
within the emergency room visit benefit category.  
 
You have also been asked to pay $209.51 for an intravenous infusion provided on January 21, 2022. This 
amount is less than the standard copayment. This item/service falls within the outpatient surgery and other 
medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
 
You have also been asked to pay $209.51 for an intravenous infusion provided on January 22, 2022. This 
amount is less than the standard copayment. This item/service falls within the outpatient surgery and other 
medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.  
 
The amount you owe is $509.02 ($90 + $209.51 + $209.51 = $509.02). 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 an emergency room visit, and intravenous infusions provided from January 20, 2022, to January 
22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. 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 the enrollee does not suffer from diabetic foot disease and the enrollee does not wear a leg 
brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage 
of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the corneal incision in the donor cornea created using a laser, 
in preparation for penetrating or lamellar keratoplasty and toric lenses (femtosecond laser procedures) (0289T) 
provided on October 27, 2021, and December 1, 2021. 
 
You asked the Plan to pay for the femtosecond laser procedures. You say that you believe these services should 
be covered because you were advised by a Plan representative that you would be reimbursed. The Plan denied 
your request. The Plan says this service is not covered, and there was no valid authorization on file for the 
services rendered. The Plan also says you contacted the Plan after these services were provided, on January 12, 
2022, and were advised that they are not covered by the Plan, and you would not be reimbursed for them. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
 
 While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. The record shows that you signed a waiver with the provider's office on October 
4, 2021, acknowledging the femtosecond laser procedures would not be covered. Therefore, we decided that 
the Plan does not have to pay for the corneal incision in the donor cornea created using a laser, in preparation 
for penetrating or lamellar keratoplasty and toric lenses (femtosecond laser procedures) (0289T) provided on 
October 27, 2021, and December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discussion of secondary membranous cataract (66821) 
provided on March 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the discussion of secondary membranous cataract. You say that as of December 
1, 2021, prior authorization is not required for services performed in an ambulatory surgical facility. You also 
say that you would like this claim to be reprocessed according to the fee schedule. The Plan denied your 
request. The Plan says this service was rendered by a non-participating provider, and a valid referral was not 
found. The Plan also says prior authorization was not obtained. 
 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 discussion of secondary membranous cataract 
(66821) provided on March 15, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM and related supplies. 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor (CGM) and related supplies. You 
say that it would be beneficial for the enrollee to have a therapeutic continuous glucose monitor (CGM). The 
Plan denied your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic CGM and related supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology, gross and microscopic examination 
(88305) provided on July 5, 2022. 
 
You asked the Plan to pay for surgical pathology, gross and microscopic examination. You say that this claim 
should be paid. The Plan denied your request. The Plan says this service was not reported with the correct code. 
 
The Plan must follow Medicare rules. Medicare rules say that prostate needle biopsy specimens from a single 
patient must be reported with one unit of service with code G0416 rather than code 88305. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of surgical pathology, gross and microscopic examination have not been met. Specifically, this 
procedure was billed with an incorrect code. Therefore, we decided that the Plan does not have to pay for 
surgical pathology, gross and microscopic examination (88305) provided on July 5, 2022.