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

 
We decided that the Plan has to pay for code 27486-AS-RT billed for date of service March 16, 2022. 
 
You asked the Plan to pay for code 27486-AS-RT. You say that the operative report supports the services as 
billed. The Plan denied your request. The Plan says that code 27486-AS-RT is not supported by the medical 
record. The Plan has paid for code 27385-AS-RT. 
 
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 27486-AS-RT is revision of total knee arthroplasty, with or without Allograft; 1 component. 
 
We asked our coder 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 code 27486-AS-RT. Our reviewer says that the billing of 
code 27486-AS-RT is supported in the medical record. Our reviewer found in the medical records, the provider 
describes working on the Tibial component and described the Revision arthroplasty as a procedure in which the 
provider removes a previously implanted artificial knee joint component, or prosthesis, and replaces it with a 
new prosthesis. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27486-AS-RT have been met. Therefore, we decided that the Plan has to 
pay for code 27486-AS-RT billed for date of service March 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on May 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility visit. You say that the patient is in a facility and the facility 
should have obtained the prior authorization. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a nursing facility visit provided on May 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. 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 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 a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81539) provided on July 12, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that prostate 4K Score genetic testing is covered when 
there is no other relative indication for prostate biopsy. 
 
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 genetic testing. Our reviewer says that 
the genetic testing was not medically necessary. Our physician reviewer found the records document that the ordering physician had indicated that the test will not assist with the biopsy decision and a biopsy was needed 
regardless of the test result. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81539) provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 21, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing identifies possible treatment options. 
The Plan denied your request. The Plan says the unique test identifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim information does not show that a DEX Z-Code was billed as 
required. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on July 25, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you cannot afford this charge. 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 $10 
copayment for Office visits. 
 
You have been asked to pay a $10 copayment for office visit. This item/service falls within the Office visits 
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 office visit provided on July 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
billed for date of service March 22, 2022. 
 You asked the Plan to pay for the billed services. You say that this is the fourth rental month. The Plan denied 
your request. The Plan says the information does not support the frequency of services. 
 
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 CPT code E0601 was billed with the KI indicator, which would indicate the second or third month 
of rental. However, the claim information shows that the KI modifier was billed for services in January and 
February. The records show that March is the fourth month of rental. A valid modifier was not billed to 
indicate the fourth month of rental. 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 
continuous positive airway pressure (CPAP) device billed for date of service March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing aids (V5130) provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for the hearing aids. You say that the Plan should be responsible 
for more than providing a discount on services. The Plan denied your request. The Plan says the copayment 
was applied correctly to your hearing aids. 
 
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. Your contract with the 
Plan clearly says that you must pay a $699 copayment per hearing aid for advanced hearing aids. 
 
We looked at the file and the Plan's rules. You have been asked to pay a total of $1,398 ($699 copayment x 2 
hearing aids = $1,398). This means you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the hearing aids (V5130) 
provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on April 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a chiropractic visit. You say that you are appealing chiropractic and physician 
services performed on April 11, 2022. You say that the provider was referred by the Plan. The Plan denied your 
request. The Plan says an authorization was not obtained prior to services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a chiropractic visit provided on April 11, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 05, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you cannot afford this charge. 
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 $150 
copayment for Outpatient surgery. 
 
You have been asked to pay a $150 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 outpatient surgery 
provided on July 05, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for removal of implantable defibrillator pulse 
generator provided on May 18, 2022. 
 
You asked the Plan to waive the coinsurance for removal of implantable defibrillator pulse generator. You say 
that you are disputing the cost share. 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 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. The allowed amount of this removal of implantable defibrillator pulse generator total 
$22,311.13, resulting in a coinsurance amount of $4,462.23. 
 
You have been asked to pay 20% coinsurance for removal of implantable defibrillator pulse generator. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 removal of 
implantable defibrillator pulse generator provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genomic sequence analysis panel provided on February 
1, 2022. 
 
You asked the Plan to pay for the genomic sequence analysis panel. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that genomic sequence analysis panels are only 
covered for certain indications. 
 
 We looked at the file and Medicare rules. This testing is only covered when the enrollee has not been 
previously tested with a CGP for the same cancer content. Review of the file shows that there was previous 
NGS testing for this enrollee. Based on this information, we decided that Medicare rules for coverage of the 
genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the genomic sequence analysis panel provided on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the procedure was done to treat the 
enrollee's condition. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no referral from an in-network provider or an approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 6, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an approved test which was provided for an 
approved indication. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on May 6, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for codes 38570-51 and 38900 billed for date of service January 27, 2022. 
 
You asked the Plan to pay for codes 38570-51 and 38900. You say that code 38570 has no bundling issues and 
code 38900 is supported by the medical documentation. The Plan denied your request. The Plan says that codes 
38570-51 and 38900 are not supported in the medical record. These codes are inclusive to 43659. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services correctly. 
 
We asked our coder 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 codes 38570-51 and 38900. Our reviewer says that based on 
coding guidelines procedure codes 38570-51 and 38900 are billed correctly and are supported by the medical 
documentations. Our reviewer found while all of the billed procedures are part of the same "family," they are 
supported when billed correctly with modifiers (as is the case here). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 38570-51 and 38900 have been met. Therefore, we decided that the Plan 
has to pay for codes 38570-51 and 38900 billed for date of service January 27, 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 the medical services provided to the enrollee on April 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that services from non-participating providers are not covered unless 
preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on 
April 22, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 42420 billed for date of service June 13, 2022. 
 
You asked the Plan to pay for code 42420. You say that this service was performed a separately duct from code 
47760 and there are no bundling edits with this code pair. The Plan denied your request. The Plan says code 
42420 is considered inclusive to code 47760. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services correctly. 
 
We asked our coder 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 code 42420. Our reviewer says that separate payment for 
code 42420 is not supported. Our reviewer found procedure code 42420 does have a multiple procedure rule 
which would mean this procedure code should have a modifier 51 added to indicate that procedure 42420 and 
47740 can properly be paid. However, because this code was not billed with this needed modifier, the denial is 
correct. 
 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 42420 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 42420 billed for date of service June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30 provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown. You say that you do not know why the tooth next to this tooth is 
approved, but the molar is not. The Plan denied your request. The Plan says the rules for D2750 have not been 
met for tooth #30. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2750) for tooth #30 provided by a participating provider.