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

 
We decided that the Plan does not have to pay for the cervical collar billed for date of service October 24, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the documentation did not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the cervical collar 
billed for date of service October 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (87798, 87150, 87481, 87801) provided on 
November 7, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that these 
services are experimental or investigational. 
 
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. In this case no medical records were provided for review. There was no 
documentation showing that the Plan tried to obtain additional information. Therefore, we decided that the Plan 
has to pay for the laboratory services (87798, 87150, 87481, 87801) provided on November 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 28, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts/orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you suffer from plantar fasciitis for the past 
year, and you need the custom feet orthotics insert. 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 pre-approve foot inserts/orthotics (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on June 14, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is 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 99213 is not supported in the medical record. Specifically, the billed code is included in 
the global package of code 20610 which was also billed. Based on this information, we decided that Medicare 
rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to 
pay for an office visit (99213) provided on June 14, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (83521) provided on January 13, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you expected these services to be paid because 
they had been covered for all of 2021. You say there may be a coding issue, but these are the same services you 
had been receiving previously. The Plan denied your request. The Plan says that these services are considered 
experimental/investigational and are considered not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for laboratory services by a contract provider. The file does not show that the Plan provided 
notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services (83521) 
provided on January 13, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2330) provided on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 January 4, 2022, and 
October 25, 2022. Therefore, we decided that the Plan does not have to pay for a filling (D2330) provided on 
December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Specifically, the record shows that the claim was billed with 
primary diagnosis code F05. This code has a code first note, which means it is a manifestation code and must 
be sequenced after an etiology code. Therefore, we decided that the Plan does not have to pay for the services 
provided on August 18, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481, 87500, 87529, 
87641, 87651, 87653 and 87798 provided October 25, 2022. 
 You asked the Plan to pay for the laboratory service. You say that due to the critical clinical value of the testing 
that benefits the enrollee, you ask for reconsideration of the denial and request payment in full for the testing. 
The Plan denied your request. The Plan says the testing is not FDA approved nor has the testing undergone 
registration with Molecular Diagnostic Services Program (MolDX). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The testing is not FDA approved nor has the testing undergone 
registration with Molecular Diagnostic Services Program (MolDX). There is not an approved technical 
assessment (TA) on file. Medicare does not provide specific coverage criteria for molecular syndromic panels 
for wound pathogen panels. As this test is not deemed to have approvable clinical scenarios and current 
outcome studies from use of these panels is limited. Based on this information, we decided that Medicare rules 
for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services coded as 87481, 87500, 87529, 87641, 87651, 87653 and 87798 provided 
October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid exam and selection (92591) provided on  
July 15, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, this service is not a covered benefit under the 
supplemental policy. Therefore, we decided that the Plan does not have to pay for the hearing aid exam and 
selection (92591) provided on July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and durable 
medical equipment (DME) repair/service (K0739). 
 
You asked the Plan to pre-approve a power seat elevation system and DME repair/service. You say that having 
the seat raise and lower makes you more self-sufficient. The Plan denied your request. The Plan says a power 
seat elevation system is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system and DME repair/service have not been met. Specifically, since a 
power seat elevation feature is non-covered, the service for adding it to your wheelchair is also non-covered. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and 
durable medical equipment (DME) repair/service (K0739).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for lumbar 
spinal stenosis with neurogenic claudication. Detailed documentation is not evident regarding dynamic 
flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. The imaging does not demonstrate any symptomatic spinal deformity or 
pseudoarthrosis. The criteria for coverage are not met and the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar spinal fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network cardiac rehabilitation 
services provided on February 25, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network cardiac rehabilitation services. You say that 
you disagree with the coinsurance. 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 40% 
coinsurance for out-of-network cardiac rehabilitation services. 
 
You have been asked to pay 40% coinsurance for out-of-network cardiac rehabilitation services. This 
item/service falls within the out-of-network cardiac rehabilitation 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 coinsurance for out-of-network cardiac rehabilitation services provided on February 
25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to 
May 7, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely. 
The Plan denied your request. The Plan says the NOA was not received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 8, 2022. The NOA was not received by the Plan. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from April 8, 2022, to May 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 12, 2022, at 
the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code F31.30, described as 
bipolar disorder, current episode depressed, mild or moderate severity, unspecified. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that documentation does not support the billed code. Our physician reviewer found the enrollee is 
noted to have had a history of depression and anxiety, and to have received her usual psychiatric medications. 
The records do not assess that the enrollee had bipolar disorder, or that any psychiatric condition affected the 
treatment provided or the length of stay of the hospitalization. As such, the billing of F31.30 as a secondary 
diagnosis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 12, 2022, at the Diagnosis Related Group (DRG) originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for dates of service August 24, 
2022, to August 31, 2022. 
 
You asked the Plan to pay for procedure code 99601. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for dates of service August 24, 2022, to August 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 14, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that the facility is responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 28, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting this to be paid without the needed 
documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code K0553 billed for date of service August 18, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that 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 K0553 is 1. The MAI value for this code is 2. You billed 1 unit of this 
code. Based on this information, we decided that Medicare rules for coverage have been met. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Therefore, we decided that the Plan has to pay for procedure code K0553 billed for date of 
service August 18, 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.