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

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on  
September 27, 2022.  
 
You asked the Plan to pay for diagnostic radiology services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the member does not have out of network benefits. 
There is no documentation that this member was referred to this non-contracted provider by a contracted 
provider, as well as no indication of any attempt made to obtain prior authorization for the out of network 
services. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on September 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on December 31, 2022, billed with 
code 0240U. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. 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 the testing services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for testing services 
provided on December 31, 2022, billed with code 0240U.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexlansopraz capsules 60 milligrams. 
 
You asked the Plan to pre-approve Dexlansopraz. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 
 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 pre-approve Dexlansopraz capsules 60 
milligrams.  
 
Benefits for Dexlansopraz 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit . You say that you would like to continue your doctor because 
hey can clearly see the change in your skin. The Plan denied your request. The Plan says this is available 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 25, 2022, 
through November 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on November 25, 2022 for the evaluation 
of hematuria after a foley insertion at another facility. He was admitted and evaluated by Urology. He required 
some irrigation of the catheter and continuous bladder irrigation. The enrollee was stable. He did not need a 
blood transfusion. The irrigation was stopped on November 26, 2022 with minimal bleeding. He was 
discharged home on November 28, 2022 when considered medically stable. The review indicates that the 
record showed that at the time of the inpatient admission the admitting physician reasonably expected that the 
enrollees necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from November 25, 2022, through November 28, 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 pre-approve complete maxillary denture (D5110), mandibular partial 
denture (D5214) and periodontal scaling and root planning (D4341). 
 
You asked the Plan to pre-approve the dentures and periodontal scaling and root planning. You say that this is 
medically necessary. The Plan denied your request. The Plan says the number of teeth in lower arch does not 
match the code requested for periodontal scaling and root planing. The Plan also says that the benefit for 
dentures has 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. The Plan covers dentures and 
periodontal scaling and root planning when the services are medically necessary and reasonable.  
 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 periodontal scaling and root planning. 
Our reviewer says that the number of teeth in lower arch does not match the code requested. Our physician 
reviewer found that there are three teeth in each of the lower quadrants. Scaling and root planning is for a 
quadrant with 4 or more teeth so the code would not apply.  
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the dentures was exhausted on dates of service April 13, 2019, and April 27, 2019. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dentures and periodontal scaling and root planning have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), 
mandibular partial denture (D5214) and periodontal scaling and root planning (D4341).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 provided on April 6, 2022. 
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 23 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
provided, were correctly coded, and were medically necessary. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88341 provided on April 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Levalbuterol. 
 
You asked the Plan to pre-approve Levalbuterol. You say that the medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 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 pre-approve Levalbuterol.  
 
Benefits for Levalbuterol 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98941 provided on September 21, 2022. 
 
You asked the Plan to pay for procedure code 98941. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 15, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure code 98941 have not been met.  
Therefore, we decided that the Plan does not have to pay for procedure code 98941 provided on September 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U provided on December 22, 2022. 
 
You asked the Plan to pay for procedure code 0241U. You say that you would like the Plan to reconsider their 
denial of payment. 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 procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U 
provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for co-surgeon services for procedure code 62230 rendered on September 
7, 2022. 
 
You asked the Plan to pay for the services. You say that this was a co-surgery, and co-surgery is allowed with 
this code and should be paid for. The Plan denied your request. The Plan says that there were no extenuating 
circumstances that indicated a need for a co-surgeon to present at a surgery that typically does not require a co-
surgeon. 
 
The Plan must follow Medicare rules. Medicare rules say that under some circumstances, the individual skills 
of two or more surgeons are required to perform surgery on the same patient during the same operative session.  
 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case.   Our physician reviewer 
found that for the requested surgery, CPT code 62230, there is a 2 under the assistant surgeon and 1 in the 
co-surgeon columns. The necessity is further supported by peer-reviewed literature. Additionally, there was a 
need to abort the first procedure and attempt another route for the attempted shunt placement. Therefore, the 
records do support that a co-surgeon was needed for this surgery. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
co-surgeon services for procedure code 62230 rendered on September 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 14, 2023. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the primary insurance explanation of benefits is 
needed to process this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has to receive an 
explanation of benefits (EOB) from the enrollee's primary insurance carrier before this claim can be 
considered. As the secondary insurer, the Plan cannot be held responsible for the imaging services provided 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on January 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit provided on 
October 14, 2021. 
 
You asked the Plan to pay for the office or other outpatient visit. The Plan denied your request. The Plan says 
according to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office or other outpatient visit  was not filed until December 20, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit provided on 
October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes 
G93.41 and J96.91 rendered from May 8, 2022, to May 11, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 diagnosis codes G93.41 and J96.91. 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 the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the enrollee had no respiratory distress and only required low dose oxygen 
support. Therefore, there was not sufficient support made for either the code, G93.41, metabolic 
encephalopathy, nor the code J96.91, respiratory failure with hypoxia.   
 
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 billed with diagnosis codes G93.41 and J96.91 rendered from May 8, 2022, to 
May 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on June 14, 2022, billed with code 
71045-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 14, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the imaging services provided have not been met.  
Therefore, we decided that the Plan does not have to pay for imaging services provided on June 14, 2022, 
billed with code 71045-26.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve SNF care. You say that you have used this provider in the past and would 
like to go there again. The Plan denied your request. The Plan says this SNF is out-of-network with the Plan 
and you can receive care within the Plan 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.
Appeal type: Lab
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 December 1, 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 
December 1, 2022.