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

 
We decided that the Plan does not have to pay for surgical services (procedure codes 20910 and 27134) 
provided to the enrollee on December 4, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 20910: 
 
Cartilage graft; costochondral 
 
CPT 27134: 
 
Revision of total hip arthroplasty; both components, with or without autograft or allograft  
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 27134, the 
procedure details cite the tripolar with the cement mantle was present on the trunnion. This was removed. The 
cement mantel was examined. It was felt to be approximately 1cm out of the cup. The cement dissociated from 
the cup itself. The cup was examined and felt to be well fixed. Both components were not revised. Therefore, 
the records do not support that CPT 27134: revision of total hip arthroplasty, both components with or without 
autograft or allograft was rendered in this case. Additionally, the records do not support that CPT 20910: 
cartilage graft, costochondral was rendered in this case. The procedure details cite that a new liner was utilized 
and was cemented. There was no indication that a cartilage graft was utilized. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 20910 and 27134) provided to the enrollee on December 4, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on September 26, 2022. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
The facility did not get the proper 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 a facility visit provided 
on September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the provided records document that the 
enrollee's most recent calcium level was below the normal range at 8.3 milligrans per decilitre (mg/dL) as of 
December 21, 2022. As stated in the Medicare-approved major drug compendia, Evenity is contraindiated for 
patients with pre-existing hypocalcemia. Evenity is therefore not safe and effective and reasonable and 
medically necessary for the enrollee. 
 
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 Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure and garment (K1024, K1032). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is considered experimental and investigational. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that pilot studies and short-term studies of 1-3 months duration were submitted by the vendor arguing 
safety and efficacy of the device. However, the provided medical records and the current peer-reviewed 
medical literature do not document that use of the non-pneumatic compression controller with sequential 
calibrated gradient pressure and garment (K1024, K1032) has been shown in controlled studies to result in long 
term health benefits in patients with lymphedema; additional studies are reported to be underway. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-pneumatic compression controller with sequential calibrated gradient pressure and 
garment (K1024, K1032).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12041 billed for date of service July 9, 2022. 
 
You asked the Plan to pay for procedure code 12041. You say that the patient was treated for multiple 
lacerations. The Plan denied your request. The Plan says 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 12041 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the RT modifier and one line 
item of this code with the RT and 76 modifiers. Based on this information, we decided that Medicare rules for 
coverage of procedure code 12041 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 12041 billed for date of service July 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on August 26, 2022, to September 26, 2022. 
 
You asked the Plan to waive the coinsurance for DME. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for durable medical equipment (DME).  
 
The enrollee has been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is 
$612.35. You are being asked to pay $122.47 ($612.35 x 20% = $122.47). This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for durable medical equipment (DME) provided on August 26, 2022, to 
September 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computerized tomography (CT) scan on 
May 18, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want to appeal the amount being 
charged. 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $547.75 and the allowed amount is $138.08. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $138.08.  
 You have been asked to pay a $138.08 copayment, which is less than the copayment for CT scan. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 computerized tomography (CT) scan on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug level testing provided on August 10, 2022. 
 
You asked the Plan to pay for drug level testing. 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 drug level testing 
provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 07, 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 
May 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services during the ostectomy services 
provided on July 8, 2022. 
 
You asked the Plan to pay for the assistant surgeon services during the ostectomy services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 28288. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
assistant surgeon services during the ostectomy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the assistant surgeon services during the ostectomy services provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on November 15, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were due a cleaning and it should be 
covered. 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 the date of service of May 17, 2022. The 
record shows your benefit for the requested item or service was not eligible until or after November 17, 2022. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on November 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that it is medically necessary for the 
enrollee to wear the compression stocking. The Plan denied your request. The Plan says the requested item is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
September 13, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $35 
copayment for outpatient diagnostic tests/Medicare-covered non radiological diagnostic services.  
 
You have been asked to pay a $35 copayment for an outpatient diagnostic test. However, you are only being 
asked to pay $12.60. This item/service falls within the outpatient diagnostic tests/Medicare-covered non 
radiological diagnostic 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 copayment for 
an outpatient diagnostic tests provided on September 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for ambulance transport provided on September 
4, 2022. 
 
You asked the Plan to waive the cost share for ambulance transport. You say that you are surprised the cost is 
so expensive for the ambulance ride. 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. Your 
contract with the Plan says that there is a $450 in-network deductible which applies to certain items and 
services. The Plan deductible applies to ambulance transports. The Plan contract says that there is a $100 in- 
and out-of-service area copayment for each one-way Medicare-covered ambulance transport.  
 
  You have been asked to pay $472.44 for the ambulance services. Since the $450 deductible has not been met, 
you pay $435.96 (remaining portion of deductible) and $36.48 copayment, which is less than the standard $100 
copayment ($435.96 + $36.48 = $472.44). The item or service you asked the Plan to waive the cost share for 
falls within the Ambulance services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $450 deductible and $100 copayment which applies to ambulance services. 
This cost sharing is a contractual obligation that had not been met at the time ambulance transport was received 
on September 4, 2022. Therefore, we decided that the Plan does not have to waive the cost share for ambulance 
transport provided on September 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care coded 99310 provided on 
June 15, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says evaluation and management codes are not covered for this 
specialty or provider type. 
 
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 99310 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive 
interval history; A comprehensive examination; Medical decision making of high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may 
be unstable or may have developed a significant new problem requiring immediate physician attention. 
Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
We find that CPT code 99310 is not supported in the medical record. Specifically, this service is not payable 
when billed with this specialty or provider type. Based on this information, we decided that Medicare rules for 
coverage of the subsequent nursing facility care have not been met. Therefore, we decided that the Plan does 
not have to pay for the subsequent nursing facility care coded 99310 provided on June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 20, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you are disputing the share 
cost. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $107.28, which is less than the $300 copayment for an outpatient surgery. 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 copayment for an 
outpatient surgery provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose test or reagent strips coded A4253 
provided on July 21, 2022, to August 20, 2022. 
 
You asked the Plan to pay for the blood glucose test or reagent strips coded A4253. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 A4253 is not supported in the medical record. Specifically, this code has a status 
indicator of "P". This means that payment for this code is always bundled into payment for other services not 
specified and no separate payment can be made. 
 
 Based on this information, we decided that Medicare rules for coverage of the blood glucose test or reagent 
strips coded A4253 have not been met. Therefore, we decided that the Plan does not have to pay for the blood 
glucose test or reagent strips coded A4253 provided on July 21, 2022, to August 20, 2022.