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

 
We decided that the Plan does not have to pay for lab services (87150, 87500, 87801) provided on August 27, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and should be paid. 
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 (87150, 87500, 87801) provided on August 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 3, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), the intraoral 
radiographic images (D0220 and D0230), bitewings (D0274), a cleaning (D1110), and drugs medicaments 
(D9630) provided by an out-of-network provider on October 31, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the provider did not tell you they were 
out-of-network prior to doing the dental services. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. Your benefit for the intraoral radiographic images has already been 
exhausted. Also, the drugs medicaments 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
record shows your benefit for the intraoral radiographic images was exhausted on date of service of October 
31, 2022. The drugs medicaments are not covered under the Plans dental benefit. Therefore, we decided that 
the Plan does not have to pay more for a periodic oral evaluation (D0120), the intraoral radiographic images 
(D0220 and D0230), bitewings (D0274), a cleaning (D1110), and drugs medicaments (D9630) provided by an 
out-of-network provider on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
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 laboratory services related to end-stage renal disease (ESRD) provided on June 15, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 15, 
2022, to July 19, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $350 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $1,400 ($350 x 4 days = $1,400). This item/service falls within the 
inpatient hospital care 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 inpatient 
hospital care provided on July 15, 2022, to July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377), power seat elevation system 
(E2300) and harness (E2313). 
 
You asked the Plan to pre-approve an electrical connection, expandable controller, power seat elevation system 
and harness. 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 wheelchair accessories are covered when specific 
criteria are met. 
 
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 an electrical connection, expandable 
controller, power seat elevation system and harness. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found a power seat elevation is not a covered item. The enrollee has 
adequate upper body strength to manage standard switches. The requested accessories exceed what is necessary 
to meet enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical connection, expandable controller, power seat elevation system and 
harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical 
connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377), 
power seat elevation system (E2300) and harness (E2313).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as the enrollee disagrees 
with the denial. The Plan denied your request. The Plan says that the services denied correctly as the enrollee 
does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM. Our reviewer says that the items 
are not medically necessary. Our physician reviewer found that the enrollee is under close f/u and adjusts 
insulin doses according to blood glucose levels; enrollee's MD advises CGM use. Enrollee meets criteria for 
CGM use. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pay for a 
continuous glucose monitor (CGM).  
 
  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 a nursing facility visit provided on July 09, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. We depend on the office staff to get prior 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 a nursing facility visit 
provided on July 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial mandibular denture (D5214). 
 
You asked the Plan to pay for the dental services. You say that you need this denture. 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 July 20, 2022. Therefore, 
we decided that the Plan does not have to pay for a partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that your provider returned the attestation form stating 
that you do not meet all three of the criteria. Therefore, you do not qualify for services under SSBCI program. 
 
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. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, we decided that the Plan has to pre-approve the 
SSBCI benefits.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0849) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that a power wheelchair is 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not have a qualifying 
condition for a Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
 
 The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy, or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (K0849) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 50715 provided on August 6, 2022. 
 
You asked the Plan to pay for code 50715. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not supported. 
 
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 50715 is ureterolysis, with or without repositioning of 
ureter for retroperitoneal fibrosis. 
 
We find that CPT code 50715 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis. Based on this information, we decided that Medicare rules for coverage of code 50715 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 50715 provided on August 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on December 13, 2022, and 
December 14, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that these medications were ordered by the 
doctor while you were in the hospital. The Plan denied your request. The Plan says the member can pay for the 
services and submit a prescription Part D reimbursement claim form for repayment. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on December 13, 2022, and December 14, 2022.  
 Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy provided on September 8, 2021, to September 
29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chemotherapy. You say that this was an emergency situation. The Plan denied 
your request. The Plan says services must be provided in-network. 
 
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 chemotherapy provided on September 8, 2021, to 
September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 8, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 8, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided September 20, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that you were told by your provider's office that 
these labs are a covered benefit. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. Medicare rules say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. We have also confirmed that code 99000 was included in the payment for another 
procedure that has already been adjudicated. Therefore, we decided that the Plan does not have to pay for the 
general health panel (80050) provided September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of blepharoptosis. 
 
You asked the Plan to pre-approve repair of blepharoptosis. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repair of blepharoptosis is only covered for certain 
indications. 
 
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 repair of blepharoptosis. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has bilateral eyelid retraction from thyroid eye disease. APer eye 
exam, photos, and visual fields, there are no medical indications for blepharoptosis repair. There are no ptosis 
documented on clinical exam; MRD1 8mm OD and 7mm OS with superior scleral show bilaterally. Photos do 
not show ptosis. Visual fields does not show superior visual field affected by upper eyelids. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repair of blepharoptosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repair of blepharoptosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
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 laboratory services related to end-stage renal disease (ESRD) provided on 
November 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
calcium scoring. 
 
You asked the Plan to pre-approve the CT scan. You say that the guidelines have been met for ordering the test. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
CT scan of the heart with calcium scoring is not medically necessary. Our physician reviewer found that the 
current evidence showing that the use of coronary artery calcium (CAC) scores in clinical management of 
asymptomatic individuals leads to changes in patient management or in individual risk behaviors that improve 
cardiac outputs outcomes is limited and inconclusive. Overall, there is insufficient support in the peer-reviewed 
literature demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of 
coronary calcium in guiding optimal management of this enrollee. As such, CT imaging of the heart without 
contrast material with quantitative evaluation of coronary calcium is considered experimental/investigational 
for the evaluation and management of this enrollee's medical condition. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart with calcium scoring.