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

 
We decided that the Plan does not have to pay for the electrocardiogram services coded 93005 provided on 
April 22, 2022. 
 
You asked the Plan to pay for the electrocardiogram services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 93005 is not supported in the medical record. Specifically, this code has a status 
indicator of Q1. Code 99284 was also billed on the same claim, with the same date of service, with a revenue 
code of 450. This gives code 99284 a status indicator of V. This means that code 93005 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram 
services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
services coded 93005 provided on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture reline (dental code D5730) provided on June 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you have always had coverage for dentures and 
were not made aware that it may have changed. The Plan denied your request. The Plan says this service is not 
covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture 
reline (dental code D5730) provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate dressing coded A6196 provided on March 9, 
2022. 
 
You asked the Plan to pay for the alginate dressing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the number of units billed is not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 120 units of CPT code A6196 are not supported in the medical record. Based on this information, 
we decided that Medicare rules for coverage of the alginate dressing have not been met. Therefore, we decided 
that the Plan does not have to pay for the alginate dressing coded A6196 provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on November 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing is supported in the medical record. 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 (G0482) provided on November 11, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on October 26, 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 that the diagnosis code is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that billed procedure code 81455 is not covered when billed with 
diagnosis code C06.2; however, the Medicare rules clearly state that this diagnosis may be one for which this 
testing is covered. The Plan has not provided any documentation or Medicare rules to support that the services 
are not payable as billed. Therefore, we decided that the Plan has to pay for the laboratory services rendered on 
October 26, 2021.  
 
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 pay for procedure code 71045 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on this date 
of service and the reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 32557.  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 71045 
is a column II code to column I code 32557. 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 71045 billed for date of service April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter tricuspid valve repair (0569T) provided 
May 24, 2022. 
 You asked the Plan to pay for the surgical procedure. You say that you are appealing the denial of payment 
because all aspects of this procedure which are a part of a clinical trial have been approved by Medicare The 
Plan denied your request. The Plan says if you participate in a Medicare-approved study, Original Medicare 
pays most of the costs for the covered services you receive as part of the study have not been met. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you must bill Original Medicare directly for this service as the enrollee was in a Medicare 
approved clinical trial. Therefore, we decided that the Plan does not have to pay for the transcatheter tricuspid 
valve repair (0569T) provided May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient meets Medicare Criteria for Acute 
Inpatient Rehab and will benefit from IRF services. The Plan denied your request. The Plan says the IRF 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that an 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 the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gym membership purchased on October 1, 2019. 
 
You asked the Plan to pay for a gym membership. You say that the member fitness rebate form states that you 
will have 24 months from the date you paid your fitness club fees to submit your request for the fitness rebate. 
You also say that you included a reimbursement request for 2019 in light of the exceptions that have been made 
for irregularities in doing business during the most intense coronavirus (COVID-19) period of 2020. The Plan 
denied your request. The Plan says you submitted for reimbursement after the deadline for submission of 
March 31st of the following year. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the reimbursement requests are received by the Plan no later than March 31st of the following year. 
 
   
The Plans rules for coverage of gym benefits have not been met because the reimbursement request was 
received after March 31, 2020. Therefore, we decided that the Plan does not have to pay for a gym membership 
purchased on October 1, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 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 99283 
is a column II code to column I code 99284. 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 99283 billed for date of service April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (0037U) provided on February 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial of payment on this 
claim. The Plan denied your request. The Plan says the claim did not contain a Dex-Z Code unique identifier 
required by Medicare. The Plan must follow Medicare rules. Medicare rules say that test providers must receive an identifier specific 
to the applicable test and submit the test assigned identifier with the claim for reimbursement. 
 
We looked at the file and Medicare rules. The records show the claim was submitted without a unique test 
identifier. Based on this information, we decided that Medicare rules for coverage of laboratory services have 
not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0037U) 
provided on February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stem cell cervices provided on September 3, 2021. 
 
You asked the Plan to pay for the billed services. You say that the records prove medical necessity. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
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 20902 bone graft, any donor area; major or large. The 
definition of code 27369 is injection procedure for contrast knee arthrography or contrast enhanced CT/MRI 
knee arthrography. The definition of code 73580 radiologic examination, knee, arthrography, radiological 
supervision and interpretation. The definition of code 25246 injection procedure for wrist arthrography. The 
definition of code 73115 is radiologic examination, wrist, arthrography, radiological supervision and 
interpretation. 
 
 
 
 We find that the CPT codes at issue are not supported in the medical record. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the stem cell cervices provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 10, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
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 the genetic testing provided on 
February 10, 2022, have been met. There is no documentation from the provider documenting the drugs being 
considered for use, and there is no documentation to show how the results will impact treatment. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on February 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 97010. The Plan denied your request. The Plan says procedure 
code 97010 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided from February 11, 
2022, to February 14, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says code G0378 
was reported more than once. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that code G0378 was billed more than once on the same date of service. This code is not allowed to be 
reported more than once per claim. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient hospital services provided from February 11, 2022, to February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided December 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for lab services (83789) provided December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 
codes 81219, 81270, 81279 and 81338. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment for NGS procedures have not 
been met. 
 
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 1, 2022, billed with codes 81219, 81270, 81279 and 81338.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on November 24, 
2021. 
 
You asked the Plan to pay for the services provided. You say that surgical lubricant is a covered expense. The 
Plan denied your request. The Plan says your plan excludes this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided 
on November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that sufficient details to support the charges billed. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided on January 3, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast reduction. 
 
You asked the Plan to pre-approve a breast reduction. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Breast Reduction is the surgical reshaping of the 
breasts to reduce or lift enlarged or sagging breasts. 
 
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 a breast reduction. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that you have macromastia. The record provided is insufficient to establish that the elements of the coverage 
criteria are satisfied. The amount of breast tissue planned to be removed is less than the amount enumerated in 
the coverage criteria. 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 a breast reduction have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a breast reduction.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 3, 2021. 
 
You asked the Plan to pay for the medical services. You say that the Plan is the primary insurer and should pay 
for these services. The Plan denied your request. The Plan says the patient has a different primary insurer, so 
the claim needs to go to them first. 
 
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 directed you 
to bill the patient's primary commercial insurance.  A Medicare Plan cannot be the primary insurer if the patient 
has a commercial plan as well.. As the secondary insurer, the Plan cannot be held responsible for the medical 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for medical services provided on November 3, 2021.